Confidential Mediation Intake Form

Confidential Mediation Intake Form

This information will not be shared with the other party unless you give the mediator(s) permission to do so.
Your Legal Name *

First Name Last Name
Preferred Name and Pronouns
Birthdate

Month Day Year
Date
Email *
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Level of conflict
Name of party in dispute with *

First Name Last Name
What is your relationship to the other person in this dispute? (E.g., partner, ex-spouse, friend, employer, tenant, landlord, etc.) *
Please give any explanation that you feel is relevant to the situation *
Are you comfortable meeting the other party virtually (Video and Audio) during mediation? *

Yes No
Mediation is a form of facilitated negotiation, by a mediator, who helps the parties engage in a dialog to search for a joint agreement. All decisions, from agreeing to participate in the mediation, to possible terms of an agreement, are decided by the parties. The mediator has no authority over the parties nor impose any directives. The mediator is there to help the parties find their interests, list and organize the options they have vs the alternatives and the outcome probabilities for each outside a resolution via the mediation process. *

I Understand
All communications in mediation are confidential, and neither the mediator's work product nor the participants' statements made in mediation about the subject matter can be disclosed later or admitted into evidence if a trial is held. Private sessions between a single party and the mediator have a second level of confidentiality, since they aren’t shared with the other party without permission. The only record of a mediation is the written agreement reached by the parties. https://www.mass.gov/info-details/about-mediation *

I have read, understand and agree with the above statement.
Signature *

Clear
Please verify that you are human *
Should be Empty: