SF PEER COURT ONLINE VICTIM IMPACT FORM

Thank you for submitting your Victim / Community Impact Statement online. Your statement will be forwarded to a staff member,
who will include it in our case preparations. The questionnaire should take between 5 and 30 minutes, depending on the amount of detail you wish to include.

The information you provide is important to our process because it helps our Peer Jury the assess the harm that was caused in the incident
and find ways to help repair that harm when they develop a disposition (or sentence) for the respondent.

Please answer a few questions, and you can type or paste written statements into the boxes provided below. If you have any questions,
please call our office at 415-865-2524, or contact us by email: Nicole@peercourt.org.

Person Making This Statement:

Please enter your name
Please enter case number

You are a
Other title
School or organization
Mailing address
City
State Zip Code
Telephone number
E-mail address
Fax number

About Your Participation:

1. Are you interested in testifying in person or witnessing this hearing? (requires program staff approval)
Yes No

2. Are you interested in guided victim/offender mediation or a similar service to reconcile personally with the offender?
Yes No

3. Do you believe you require further mental or physical health services as a result of being victimized?
Yes No
If you answered "yes" to #3, or if you feel as though you require further legal assistance, please contact the District Attorney's Victim Services Unit at (415) 553-9044

Physical Harm:

4. Did you experience any physical harm as a result of this incident?
Yes No If so, please describe:

Emotional or Psychological Harm:

5. Did you experience any emotional or psychological harm as a result of this incident?
Yes No If so, please describe:

Financial Harm:

6. Did you experience any OUT OF POCKET expenses as a result of this incident?
Yes No

7. Are you seeking RESTITUTION from the respondent as a result of this incident?
Yes No If so, amount for which you will provide documentation to our staff:

Please explain your financial damages and why you believe you are owed restitution:

Resolution:

8. Do you have recommendations as to how you would like to see this incident resolved?
Yes No
If so, please make your statement here:

Anything Else?

9. Is there anything else you would like to mention about this incident, or the impact it has had on your life and the lives of others, for the court to consider?
Yes No
If so, please make your statement here:

Please use this online form to submit your statement, or you can submit the necessary information by fax,

direct mail, or PDF email. If you have any questions or concerns, please contact:

Nicole Brown, RJAY Referrals
California Community Dispute Services
149 Natoma Street, Third Floor
San Francisco, CA 94105
Nicole@peercourt.org
Phone (415) 865-2524
Fax (415) 865-2538

Please submit only once, and be patient as your form loads (it may take a few moments). You will be shown a confirmation once it has been sent.