Mediation Intake Form
Please complete this form to request mediation. The information will help the mediator understand basic issues about you and the dispute. Completing and submitting the form does not require you to participate in mediation. You will not be committed to mediate or to pay fees until you and the others involved in the dispute agree to mediate by signing our Agreement to Mediate.
Contact Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
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Attorney Information
If you have an attorney representing you in connection with this dispute, please include their information.
Do you have an attoney for your matter?
*
Yes
No (Please skip to 'Opposing Party' section)
Attorney Name
First Name
Last Name
Attorney Email
example@example.com
Attorney Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney Phone Number
Please enter a valid phone number.
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Opposing Party Information
Please include any information you have about the Opposing Party.
Name
*
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Opposing Party's Attorney
First Name
Last Name
If you believe you are the first person to contact the mediator, have you contacted the other party to the dispute about using a mediator to resolve this issue, or would you prefer we contact them for you?
I HAVE NOT contacted the other party. Contact them for me.
I HAVE contacted the other party.
I have contacted the other party and they seem willing to mediate.
I will contact the other party and advise them I would like to mediate.
I have already agreed with the other party to use mediation.
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Case Status
If a court case has been filed by you or the other party, please complete this section.
Has a court case been filed?
*
Yes
No (Skip to next section)
Unsure
Name of Court
Case Number
Name of Case
Next Hearing Date
Relief Requested
Money / Damages
Non-Monetary Relief (e.g. injunction)
Please upload any copies of pleadings you may have regarding your matter. NOTE: DO NOT INCLUDE ANY CONFIDENTIAL OR PRIVILEGED MATERIALS FROM YOUR ATTORNEY. IF YOU HAVE QUESTIONS ABOUT WHICH DOCUMENTS ARE CONFIDENTIAL OR PRIVILEGED, PLEASE CONTACT YOUR ATTORNEY.
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Supplemental Information
When was your last contact with the opposing party regarding this dispute?
Are there any other people involved in the dispute who may have important information pertaining to the dispute? If yes, please list them below.
What other information would you like us to know?
Should be Empty: