NEW MEDIATION CLIENT INTAKE
Welcome to Bassa & Associates, LLC. Take a few minutes to complete our New Client Intake Form and schedule your session. Please allow up to three (3) business days for an appointment confirmation response.
BASIC CLIENT INFORMATION
Name
*
Mr.
Mrs.
Prefix
First Name
Middle Name
Last Name
Business/Company/Organization Name (if applicable)
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Best Telephone Number to Reach You
*
-
Area Code
Phone Number
Secondary Number (if applicable)
-
Area Code
Phone Number
Email Address
*
example@example.com
CLIENT PREFERENCES
What is your preferred method of contact?
*
Primary Telephone
Secondary Telephone Number
Email
MEDIATION DETAILS
What type of mediation are you requesting?
*
Relationship Mediation (Includes family, marriages, friends, etc.)
Business/Employment Mediation
Other (Please add details in next section)
It is important that you get what you need out of each mediation session; therefore, help us help you by listing the issues that you want resolved during our session(s) in order of priority:
*
The Participants
Name(s) of other individual(s) involved in conflict:
Person #1:
*
Prefix
First Name
Middle Name
Last Name
Person #1's Telephone Number:
*
Please enter a valid phone number.
Person #1's Email Address:
*
example@example.com
Person #2:
Prefix
First Name
Middle Name
Last Name
Person #2's Telephone Number:
Please enter a valid phone number.
Person #2's Email Address:
example@example.com
Please list any other individual(s) involved with this mediation who are not mentioned above and their contact information:
SCHEDULING PREFERENCES
Help us schedule the best appointment for you!
What days & times work best for scheduling? Please check all that apply.
*
Mon
Tue
Wed
Thur
Fri
Sat
Sun
Morning (9am - 11:30am)
Mid-Day (11:30am - 1:30pm)
Afternoon (1:30pm - 4pm)
Evening (4pm - 7pm)
How did you hear about us?
*
Please Select
Online/Google Search
Social Media (Facebook, Instagram, TikTok, LinkedIn, etc.)
Friend/Family Referral
Newspaper/Magazine
Commercial Ad (Radio/TV)
Submit
Should be Empty: