Mediation Intake Form
General Information
Each party is required to complete and provide to Citron Consulting within 7 days of booking a mediation to enquiries@citronconsulting.com.au. This form provides the mediator with important information about the matter, the history and issues in the case. It takes 5-10 minutes to complete and done in collaboration with legal representatives (if engaged) or a party can complete on their own behalf. Information provided will be used in the confidential pre-mediation conference
Client Name
First Name
Last Name
Client Email
example@example.com
Client Phone Number
Please enter a valid phone number.
Client Address
Street Address
Street Address Line 2
City
State / Territory
Postal Code
Legal Representative (only complete if represented)
Name
Law Firm
Legal Representative Email
example@example.com
Legal Representative Phone Number
Please enter a valid phone number.
Legal Representative Address
Street Address
Street Address Line 2
City
State / Territory
Postal Code
Corporate Representative (only complete if workplace or contractual dispute)
Representative Name
Company
Corporate Representative Email
example@example.com
Corporate Representative Phone Number
Please enter a valid phone number.
Corporate Representative Address
Street Address
Street Address Line 2
City
State / Territory
Postal Code
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What type of dispute?
Please Select
Employment matters
Commercial
Statutory / Legal
Wills & Estates
Family
Local government
Other
Has this matter previously been mediated?
No
Yes - if yes please provide details below
Provide short summary on the issue and desired outcome
File Upload - Full details of issue (up to 4 pages PDF)
Browse Files
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Choose a file
Cancel
of
File Upload - Supplementary documents (No more than 4 documents relevant to mediation such as photos, emails, plans, agreements or contracts)
Browse Files
Drag and drop files here
Choose a file
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of
Will you be bringing a support person?
First Name
Last Name
Support person relationship
Preferred type of mediation
Face-to-face / in person
Online
Telephone
Other
Cultural information relevant for mediation
Anticipated length of time for mediation
Up to 2 hours (minimum)
Half day (2-4 hours)
Full day (4 to 7 hours)
Other
State anticipated length of time if Other
Is shuttle mediation required?
Yes
No
Preferred location for mediation (if in person)
Company office
Mediator office
Legal representative office
Other - please state below
State preferred location if Other
Health and Wellbeing It is important that parties attending the mediation feel well, alert, and able to focus for long periods on the discussion about their issues. Please provide details on any physical or mental health issues that may impact the party to participate in mediation.
Reasonable Adjustments - Please provide details if you have disability requirements on the day of mediation.
Any further details?
Certification - This information is true and accurate
First Name
Last Name
Date
Signature
Submit
Should be Empty: