CJP Referral Form for Community Services Mediation and Restorative Justice Referral Form (click here to view/download) This form is to be used by organizations and individuals wishing to refer a conflict to mediation services provided by PDRC. To make a referral, check with at least one of the participants to make sure they want the case to go to mediation. If both parties do not agree to mediation conflict coaching is available to individuals. Please complete this form and submit below. The form may also be sent via Fax: (540) 347-4689 or email: cjp.pdrc@gmail.com to PDRC. If you have a general question, please call PDRC at 540-347-6650. Please enable JavaScript in your browser to complete this form.Referrer’s Name:Phone:Organization/Agency:Email:Fax:Request for follow-up on the status of mediation case?YesNoToday's Date:Choose Type of Dispute *FamilyShared ParentingSchoolNeighbor to NeighborEmployee/EmployerBusiness/ConsumerLandlord/TenantVictim/OffenderOtherBrief description of the conflict:Participant #1 Name:Has this person agreed to try mediation?YesNoAddress:Telephone:Email:Participant #2 Name: Has this person agreed to try mediation? YesNoAddress:Telephone: Email:Other important information:CommentSubmit Share this:TwitterFacebookLike this:Like Loading...