Mediation Referral Form

This form allows you to refer to PCRC parties you believe could benefit from our services. It also lets you open a mediation case for yourself! If you have any questions about whether a situation is appropriate for referral, please do not hesitate to call us at 650-513-0330.

Before sending this form, we ask that you do the following:

1. If you are referring others, please inform them that you are making this referral.
2. Please provide as much of the following contact information as possible for all the individual(s) involved.

1. First Party Information

Name

Phone

Street Address

City

ZIP Code

Language spoken

English

Spanish

Other (Please specify in Summary field, below)

2. Second Party Information

Name

Phone

Street Address

City

ZIP Code

Language spoken

English

Spanish

Other (Please specify in Summary field, below)

3. Why are you referring these individuals?

Summary of Issue

4. To which program are you referring these individuals?

Program

Community Mediation

Parent/Teen Mediation (Please indicate which party is the parent and which is the teen in the Summary field, above.)

Other (Please explain in Summary field, above.)

5. Your Information

Name

Affiliation

None

Police

Sheriff

City (Please indicate which city, below)

Other (Please include in Summary field, above)

City

Phone

Email

If referred by law enforcement, please enter the case number if available:

6. Please provide any other information you feel would be helpful for us to know.

Please enter the code