Adult Referral Form Restorative Justice | Le Chéile Mentoring

Tel: 01 214 4350 – Email: info@lecheile.ie

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Adult Referral Form Restorative Justice

Service

Service:

Referred Persons Details

First Name
Last Name
Date of Birth:
Gender:
Nationality:
Nationality Other:
Ethnic Group:
Ethnic Group Other description:

Referrer Details

Referrer First Name:
Referrer Last Name:
Referrer email:
Referrer Mobile:
Referral Agency:
Referral Agency Other Note:
Adjourned Supervision:
Detention and Supervision Order:
Probation Bond:
Initial Assessment PSR Stage:
Status with Referral Agency Other Note:
Length of Order/Sentence (Months):

Referred Person Details

Street
City
County
Eircode
Country

Phone
Mobile

Referred Person Spouse or Partner

Partner Name:
Partner Phone:
Partner Address:
Partner Relationship to Person:

Household

Residing With:
Does anyone else live with the person referred?
Highlight strengths and challenges in the family/living arrangements:

Offending Behaviour, Risks and Threats

Arson:
Assault Sect 2:
Assault Sect 3:
Attempted Robbery:
Robbery:
Burglary:
Criminal Damage:
Drunk & Disorderly:
Handling of Stolen Property:
Intoxicated:
Money Laundering:
Possession of drugs for own use:
Possession of drugs for sale & supply:
Possession of a Weapon:
Public Order:
Road Traffic (Driver):
Road Traffic (Other):
Sexual Offences:
Theft:
Trespass:
Other Offending Beh & Threats:
Parent Mentoring Referral:
Details of offence against a person:
Is the person under threat from others:

Substance Use

Alcohol:
Benzodiazepines:
Cigarettes:
Cocaine:
Ecstasy:
Heroin:
LSD:
Marijuana:
Solvents:
Prescribed Medication:
Not Known (substance):
Other Substance Use Note:

Medical History

Known medical and health issues:

Learning Difficulties

Literacy:
Dyslexia:
ADHD/ADD:
Numeracy:
Autistic Spectrum:
Other Learning Difficulty:
Other Learning Difficulties Note:

Health and Safety

Health & Safety areas need to be aware of:
Does person pose a risk to self/mentor:
Health and Safety Details (if yes):

Reason for Referral

Please outline why you are referring the person for Restorative Justice and the benefits you hope they will gain from it:

Additional Information

Other relevant info about person:
Education training or employment:
Currently involved with other services:
Other services details:
Have you discussed Le Cheile w Person:
If No, please give details:

Restorative Intervention Initial Suitability Screening

Guilty Plea:
No Plea Full Admission:
Partial Acceptance Undermines Process:
Restorative Approaches Explained:
Further Assessment Willing/Agreeable?:
Referred Person appears motivated?:
Issues pertaining to Victim?:
Issues pertaining to Victim - Details:
Other concerns of any nature?:
Other concerns details:

Suitable for further assessment?:
Checklist Completed by:

Restorative Justice Referrals Only

Victim/Offender Mediation:
Reparation:
Victim Empathy Programme:
Restorative Justice Meeting:
Reason for referral and model chosen:
RJ Approx Start date:
RJ Approx End date:

Data Protection

By submitting this form, you are confirming that you have fulfilled the obligations placed on the collection and processing of personal and special category personal data as outlined by GDPR and that the data submitted to Le Cheile in this form has been collected and processed in compliance with GDPR.

Contact us

Le Chéile Mentoring,
24 Tivoli Terrace South,
Dún Laoghaire,
Co. Dublin.
Tel: 01 214 4350
Email: info@lecheile.ie

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