Mediation Intake Form
About You
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Do you have an Attorney
*
Yes
No
Attorney Information
If you have an attorney representing you in connection with this dispute, please include their information
Attorney's Name
First Name
Last Name
Attorney's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Attorney's Email
example@example.com
Attorney's Phone Number
Please enter a valid phone number.
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Other Party's Information
Please include any information you have.
Opposing Party Full Name
*
First Name
Last Name
Opposing Party: Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Opposing Party Email
*
example@example.com
Opposing Party Phone Number
*
Please enter a valid phone number.
Does the Opposing Party have an Attorney?
*
Yes
No
Opposing Party: Attorney Information
If the other party has an attorney, please include any information you have.
Opposing Party Attorney's Name
First Name
Last Name
Opposing Party Attorney's Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Opposing Party Attorney's Email
example@example.com
Opposing Party Attorney's Phone Number
Please enter a valid phone number.
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 , however they are not certain they want to mediate or don’t want to. Contact them for me.
I have contacted the other party and they seem willing to mediate. Contact them for me.
I will contact the other party for the first time.
I will try once more to contact the other party and ask them to mediate our dispute.
I have already agreed with the other party to use mediation.
I am the other party and I have agreed to mediate the dispute.
Please tell us what the issue is. You should check all areas that apply.
*
Divorce/Separation
Child Custody
Child Support
Property Settlement
Other Family Issue
Guardianship/Conservatorship
Elder Care
Decedent’s Estate or Trust
Employment Issue
Workplace Conflict
Faith-Based
Please describe what has occurred.
*
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Case Status
If a court case has been filed by you or the other party, please complete this section and provide us with a copy of all pleadings from the case that you have, including a copy of any order to mediate. DO NOT INCLUDE ANY CONFIDENTIAL OR PRIVILEGED MATERIALS FROM YOUR ATTORNEY. IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT WHICH DOCUMENTS ARE CONFIDENTIAL OR PRIVILEGED, PLEASE CONTACT YOUR ATTORNEY IMMEDIATELY.
Has a case been filed with the court?
*
Yes
No
Name of Court
Ex: Collier County Circuit Court
Case Number
Name of Case
Next Hearing Date
Previous Hearing Date and Outcome
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Relief Requested
What type of relief are you requesting?
*
Money/Damages
Non-Monetary Relief (e.g., injunction, other)
Please Describe
*
Do you have any safety concerns involving the potential participants in the mediation?
*
Yes
No
Please Describe
Do you prefer meeting in an online format?
*
Yes
No
Are you willing to meet with the other party in the same room?
Yes
No
Are there any other special needs or issues that we should know about?
*
Yes
No
Please Describe
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Dispute and Desired Result
Please provide a brief description of the events to date.
*
Please discuss what you are hoping for as a resolution of the dispute (e.g., Resolution of an issue regarding money? How much, and how is that amount calculated? Resolution regarding something other than money? Apology? Having the other party stop doing something? Start doing something? What else? What is your “ideal” result?)
*
What actions have you taken to resolve the dispute?
*
What other actions do you believe you need to take to resolve the dispute?
*
What actions, if any, has the other party taken to resolve the dispute?
*
What actions do you believe the other party should take to resolve the dispute?
*
What was your last contact with the other party about this dispute?
*
Are there any other people involved in the dispute or who have information about the dispute?
*
Yes
No
What is their name, relationship to you or the other party, and describe how they are involved in the dispute.
Is there someone besides you and the other party that need to attend mediation in order to resolve the dispute?
*
Yes
No
Please explain who and why
Will you need approval from anyone other than yourself to come to an agreement about this dispute?
*
Yes
No
Who?
What other information would you like us to know?
*
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Do you need Financial Assistance with your mediation fees?
*
Yes
No
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Thank you!
Please provide copies of/upload any documents you believe are important. Do not give us any confidential documents yet, or privileged documents from your attorney. We will explore exchanging confidential documents once the Agreement to Mediate is signed. Please take a moment to double check your information.
Submit
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