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Mediation Intake Form
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Your Contact Information
Name
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First
Last
Phone Number
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Email Address
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Address
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Line 1
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City
State
Zip Code
Country
Other Party's Contact Information
Name
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First
Last
Phone Number
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Email Address
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Address
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City
State
Zip Code
Country
If you are the first person to contact the mediator, have you contacted the other party about using a mediator to resolve this case?
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I will contact the other party
I have already agreed with the other party to use mediation as a means to attempt to resolve our dispute
I am the “other party”, and agree to mediation as a means to attempt to resolve our dispute
Your Attorney's Information
Are you currently represented by an attorney?
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Yes
No
Other Party's Attorney's Information
Is the other party currently represented by an attorney?
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Yes
No
If yes, please provide the following information:
Name
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First
Last
Firm Name
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Phone Number
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Email
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Address
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Line 1
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City
State
Zip Code
Country
If yes, please provide the following information:
Name
*
First
Last
Firm Name
*
Phone Number
*
Email
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Case Information
What is your relationship to the other party?
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If there is an ongoing relationship, is it important to you to preserve that relationship?
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Yes
No
N/A
Why or why not?
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Please (briefly) describe the current issues or dispute:
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Please summarize your most important concerns to be addressed in this mediation:
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Please summarize your goals for this mediation:
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Please summarize what you believe to be the other party’s most important concerns:
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Please summarize what you believe to be the other party’s goals for this mediation:
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What actions, if any, do you believe you need to take to resolve this situation?
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What actions, if any, do you believe the other party needs to take to resolve this situation?
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Would you have any concerns about being in the same room with the other party in an effort to resolve the matters in dispute?
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Yes
No
Please explain your concerns, if any:
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Would you prefer to have someone accompany you if the matter is mediated?
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Yes
No
If yes, please state the person’s name, full contact information, relationship to you and describe how that person will be of help to you in the mediation:
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Is there any other information that you would like to provide?
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Date
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By clicking the "submit" button, I certify that the above information is accurate to the best of my knowledge.
Note: All information you provide on this form is subject to confidentiality, and will remain confidential unless you authorize us to discuss any portion thereof with the other party and/or their representatives.
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