Civil Discourse Mediation Services

Civil Discourse Mediation Services

Mediation Request Form
Please complete the Mediation Request Form to request mediation services. Please include all issues you would like to mediate along with any relevant information that will affect the party’s ability to make an informed decision. Information for all parties who will be a part of the mediation is required, and all parties must agree to mediate. Your request will be reviewed for best next steps.
Party 1 (Requestor)

First NameLast Name
Contact Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there an attorney representing Party 1?
If yes, please provide attorney name and contact information
Party 2

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Is there an attorney representing Party 2?
If, yes, please provide the attorney's name and contact information
Briefly describe the nature of the dispute and what items you would like mediated?
Please select a date and time that works best for a 30-minute consultation?
Any other specific date and time, if the above selection is not suitable.

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: