Conciliation Client Information Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Date of Birth
Marital Status
Single
Married
Separated
Divorced
Widowed
Occupation
Type a question
If this is a marriage or family dispute, please provide the names and relationships of involved family members.
If you have talked with an attorney about your dispute, or intend to, please provide the attorney's name and contact information.
Describe any legal action that has been filed regarding this dispute.
Information about Other Party
Please provide as much information as possible regarding the other party in this dispute.
Name of other party in dispute
First Name
Last Name
Email of other party in dispute
example@example.com
Address of other party in dispute
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of other party in dispute
-
Area Code
Phone Number
Information Regarding Dispute
Please provide the following information regarding the dispute.
Briefly describe your problem or dispute (you can give more detailed information during conflict coaching):
What have you done to try to resolve this problem or dispute?
What are the issues or questions you want to have resolved or answered?
What are your hopes and expectations for this process?
What do you want from the other party?
What other information should we know?
Terms and Conditions
I agree that any dispute with Level Path Ministries LLC or any mediator arising from or relating to this agreement shall be settled by mediation and, if necessary, legally binding arbitration in accordance with the Rules and Procedures for Christian Conciliation promulgated by the Institute of Christian Conciliation, I agree that judgment upon an arbitration decision may be entered into any court of competent jurisdiction. I agree that these methods shall be my sole remedy and expressly waive my right to file a lawsuit in any civil court for any claim arising out of or in any way related to this agreement, except as necessary to enforce an arbitration decision.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: