Please fill the following form.

Restorative Justice Referral
RJ Programs Roster: https://www.alberta.ca/restorative-justice
Instructions - Once a restorative justice (RJ) referral is agreed upon between defense counsel and prosecution:
1)Referring prosecutor completes Page 2 before sending to defence counsel.
2)Defense counsel and the accused person completes Page 1, signs Page 3, and then returns to the referring prosecution office.
3)Referring prosecutor signs Page 3 and forwards completed form and victim(s) contact information to RJ service provider.
The personal information collected through the Restorative Justice Referral is for the purpose of facilitating restorative justice referrals between the Alberta Courts and approved restorative justice organizations listed online at Restorative justice | Alberta.ca. The information will be shared with defense counsel, members of the Judiciary and the Alberta Crown Prosecution Service, and program staff of the approved restorative justice organization to which it is referred. This collection is authorized by section 4(c) of the Protection of Privacy Act. For questions about the collection of personal information, contact the Director of Community Safety Initiatives Unit by email at RJProgram@gov.ab.ca, or telephone at 403-816-4096, or mail to #500, McFarlane Tower, 700 4 Avenue SW, Calgary, AB, T2P 3J4.
Completion of all fields is required. Indicate N/A as needed.
Has the Accused participated in RJ processes in the past?
Date of Birth:
Custody Status:
No Contact Order
(from RJ Programs Roster referenced above)
Purpose of referral:
DSS14822 Rev. 2025-08
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Charge
Offence Date
Docket Number
Police File Number
Crown Resolution Position
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**The Crown requires correspondence regarding the completion of the RJ process prior to summarily disposing of the matter as set out above. The Crown reserves the right to return the matter to regular prosecution or to withdraw the resolution position set out above when confirmation of completion is not provided.
Signatures
Please send the completed referral form, along with victim(s) contact information, to the RJ program to whom you make this referral.
DSS14822 Rev. 2025-08
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