General Mediation Request : Mediation West

General Mediation

Mediation is a voluntary process and Mediation West is one provider of this service.
Before you begin. Please note that you will need the following to complete your form for mediation:
- Contact information for the other participant
- Your court case number (if filed in court)
You will also need to submit one of the following payment options:
- $479
  - This covers the cost of your mediation unless following your mediation you, the other participant, and the mediator decide together on additional sessions. Those sessions would require additional payment.
- $159
  - This covers an initial installment. The office will contact you with your generated payment schedule for two remaining installments of $160. This is generally spaced out over 4 weeks but may vary depending on how long a mediation has been active in our system.
- $39 non-refundable payment and a reduced fee application.
  - This grant-subsidized option requires income verification. This can be last year's tax return, your last two consecutive paystubs, or a letter from a government agency stating the approval amount for state benefits of some kind such as unemployment, SNAP, ADC, etc.
Are you requesting a NEW mediation, or did Mediation West contact you about an invitation to mediate from someone else? I am:*

Requesting a NEW mediationResponding to an EXISTING invitation to mediate
What type of mediation*
How did you hear about us?*
Mediation is a voluntary process and Mediation West is one provider of this service.

You or the other party may decline the invitation to mediate through our office and may work to resolve your issues through:
- direct negotiation with the other person(s)
- a private mediator
- the self-help section on the Nebraska Supreme Court Website
- a settlement conference between attorneys
- or any other means approved by the Court
Code of Conduct Agreements

I am choosing to move forward with a voluntary case using Mediation West’s services and by doing so I acknowledge and agree to Mediation West’s Code of Conduct as stipulated in their Policy.
File number provided in your invitation from Mediation West*
Do you want to accept the invitation to mediate?*

Yes please, I doNo thank you, I do not

Code of Conduct Agreement
I am choosing to move forward with a voluntary mediation using Mediation West’s services and by doing so I acknowledge and agree to Mediation West’s Code of Conduct as stipulated in their Policy.
Behavior Agreement*

By checking this box I agree to abide by the section labeled "Behavior." I understand this means I will be polite and cooperative with the other participant(s) and Mediation West staff and mediator(s).
Lack of Mediation Progression Agreement*

By checking this box I agree to abide by the section labeled "Lack of Mediation Progression." I understand this means I will meaningfully mediate with the other party/parties in my case.

About You
Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
I agree to accept texts at this number*

Yes, pleaseNo, thank you
Email*
example@example.com
I regularly check this email*

Yes, I doSorry, I do not
My preferred form of contact is:*

About the Other Person to Mediate With
Name of the Other Person*

First NameLast Name
Preferred Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
I anticipate their preferred form of contact is:*
Do you think the other person is expecting to hear from us?*

YesNoNot sure
How do you think the other person will respond to the invitation to mediate?*

About the Relationship
What is your connection to the other person? *
How long have you known the other person? *
Is there a history of harassment orders, protection orders, or police calls?*

YesNoNot sure
Briefly describe the circumstances surrounding the harassment order(s), protection order(s) or police call(s)*
Is there a current protection order in place?*

YesNoNot sure
Does the current protection order include child(ren)?*

YesNoNot sure
Is there anything more you'd like us to know about your case?*

Release of Information
About Mediation

By signing below, you consent to a facilitated conversation with the Mediation West mediator and any other professionals/support persons appropriate for your case, according to the current Mediation West Policy. Highlights of the policy include:
- Mediation is voluntary. This means that agreements cannot be forced upon you even if you are court-ordered to participate in the process.
  You have the option to review any agreements with an attorney before signing if you wish.
- Mediation West keeps the content of your sessions confidential but may need to report process information such as progress and scheduling.
- Mediator notes are private. Your attorney can have access to any reports produced for the Court.
- You agree to keep the content of the session confidential and agree:
  - Not to record or transcribe sessions.
  - Identify anyone who could potentially overhear a session if joining by phone or video conference.
  - Recordings/transcriptions of sessions are not admissible in court and allowing other people to listen to sessions is strictly forbidden and may void any agreement reached.
Mediation West may share information about your case under certain circumstances. If you would like us to release/receive information to/from someone, we need your authorization by completing below:
Release of Information to the following:

Mediation Cost/Fees
Fees for services are due and payable before sessions can be scheduled and refunds are limited (to read the full policy click here).
Mediation West has been approved funding through a government grant to help supplement the cost of mediation for those who qualify. We are excited to be able to offer this option to our clients. To use these funds, however, we must supply the grantor with verification of income that falls within the range they specify.

The verification of income documents they allow is any one of the following options:
- The last two consecutive paystubs from your employment
- The first two pages of last filed income tax return
- A benefits confirmation letter specifying the amount of benefit qualified for/being received from a government agency (ie Unemployment, SNAP, ADC, etc.)
- A declaration signed by a judge of Informa Pauperis status
- Verification of incarceration
Please choose one of the following payment options:*

Apply for Reduced Fees & pay application fee - $39Make Payment Installments - $159 today and 2 additional of $160Make Full Payment - $479
When submitting your case today, you will need to submit a $39 payment, complete the reduced fee application on the next page, and upload the required income verification. Once your application for reduced fees is processed, you will receive a link with the balance due and instructions for submitting your payment.
When submitting your case today, you will need to submit your initial installment of $159 payment. You will be contaced with your schedule for the 2 remaining installments of $160.

Application for Reduced Fees

Mediation West offers a sliding fee scale based on your household size and income. You will need to provide income verification for each adult counted in your household size to pass audit requirements.
Number of adults in your household*
(*Note each adult listed must provide income verification in order to be counted toward the household total. If there are adults in your home who do not have appropriate income verification please exclude them from your count.)
Number of children that live in your household more than 50% of the time*
Total annual gross household income before deductions*
Which type of income verification will you be uploading?*

The last two consecutive paystubs from your employmentThe first two pages of last filed income tax returnA benefits confirmation letter specifying the amount of benefit qualified for/being received from a government agency (ie Unemployment, SNAP, ADC, etc.)A declaration signed by a judge of Informa Pauperis statusVerification of incarceration
Income verification document*

Please note you may upload multiple files to this same section, however an additional box is located below for 2 separate uploads if you prefer or run into problems with multiple file upload.
Cancelof
Paystub #1*

Please note you may upload multiple files to this same section, however an additional box is located below for 2 separate uploads if you prefer or run into problems with multiple file upload.
Cancelof
Paystub #2

Cancelof

Confirmation
You are {areYou} and have responded "{doYou144} want to participate".
You are {areYou} and selected to pay ${pleaseChoose} today.
Typing and writing in the boxes below shall constitute an electronic signature and, along with processing my payment, constitutes valid evidence of my consent to mediate under the policies of Mediation West.

I, {name}, understand I am solely responsible for reviewing and understanding all the terms and conditions. I agree the electronically stored copy of this consent is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.
I accept
First NameLast Name
Signature*

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Total Due Today*
Payment Amount*

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General Mediation

Before you begin. Please note that you will need the following to complete your form for mediation:

Code of Conduct Agreement

About You

About the Other Person to Mediate With

About the Issues

About the Relationship

Release of Information

Statistical Information

Mediation Cost/Fees

Application for Reduced Fees

Confirmation