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DA Pre-Process Screening
Case ID Number: (No symbols, numbers only)
*
Date
*
MM slash DD slash YYYY
Who was harmed in your case?
Did you know the victim before the offense?
Yes
No
There was no direct victim
If yes, how did you know them?
My offense harmed the victim:
1 Not at All
2
3
4 Somewhat
5
6
7 Very Badly
Please mention HOW you think your offense harmed the victim:
My offense harmed the community:
1 Not at All
2
3
4 Somewhat
5
6
7 Very Badly
Please mention HOW you think your offense harmed the community:
My offense harmed my family:
1 Not at All
2
3
4 Somewhat
5
6
7 Very Badly
Please mention HOW you think your offense harmed your family:
My offense harmed me:
1 Not at All
2
3
4 Somewhat
5
6
7 Very Badly
Please mention HOW you think your offense harmed you:
What do you think could be done to repair the harm caused?
Please answer the following questions by circling the number that best describes how you feel right now on a scale of 1 to 7. Please answer as honestly as possible.
Right now, how do you feel about yourself?
1 Awful
2
3
4 Neutral
5
6
7 Happy With Who I Am
Right now, how do you feel about what you've done?
1 Doesn't Bother Me At All
2
3
4 Neutral
5
6
7 Can't Stop Thinking About It
Right now, how much do you worry about what other people think of you?
1 Not at all
2
3
4 Somewhat
5
6
7 Very much
For the most part, how much do you agree with the following statements currently:
I have done something that needs to be made right:
1 Not at all
2
3
4 Somewhat
5
6
7 Very much
I feel like my community cares about me:
1 Not at all
2
3
4 Somewhat
5
6
7 Very much
My case is being handled fairly:
1 Not at all
2
3
4 Somewhat
5
6
7 Very much
What do you hope will happen during the Restorative Justice process?