FORM FOR PROCESSING COMPLAINTS

NAME OF COMPLAINANT:

NAME OF OTHER INVOLVED:

NATURE OF THE INCIDENT:

TIME OF DAY:

PLACE OCCURED:

WITNESSES (IF ANY):

YOUR WISHES OR IDEAS FOR A SKILLFULL RESPONSE TO THIS ISSUE:

PREFERRED DYNAMICS OF HEALING:

Education of party involved by a third party:

Face to face restoration process:

Acknowledgement of incident as upsetting and willingness to

refrain from the behavior:

Amends, apology, spoken or written understanding:

Anonymity:

Follow-up assessment (evaluation of expected outcome):

Other: