Employment First Mediation

Employment First Mediation
This form is designed to gather the basic information we will need to start working on your Employment First mediation request.

Please allow 5-10 minutes to fill out this form. Before you get started, make sure you have the following:
- The master case number for your DHHS case.
- Contact information for any additional individuals with which you wish to share your information.
How did you hear about us?
Legal Name

First NameLast Name
Preferred Name

First NameLast 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:

YesNo
Email
example@example.com
What is your preferred form of contact?
DHHS Master Case Number:
Please tell us about the problem you would like to solve through mediation:
Where do things stand in your attempt to work things out with the other person(s)?

Consent
Consent to mediate*

I agree that providing my electronic signature below and submitting this form, constitute valid evidence of my consent to mediate under the policies of Mediation West. I 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.
Signature*

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