MDRS Client Intake Form

Client Intake Form

Mediation is a voluntary, confidential process
Full Name*

First NameLast Name
Date Of Birth

MonthDayYear
Contact Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you represented by an attorney?*

YESNO
Name of Attorney
Have you every participated in mediation before?

YESNO
Brief description of the issue(s) to be mediated:*
Name of other party involved:*
What is your relationship with the other party?*
Preferred time/day to mediate: *
Language preference
Is an interpreter needed?*

YesNo
Please verify that you are human*
Terms and Conditions

All information shared is private and confidential to the extent permitted by law. This information will only be used to provide services through Mediation Dispute Resolution Specialist, "MDRS" Information will not be shared with third parties without your written consent, except where disclosure is required by law. Examples of mandatory reporting include threats of harm to self or others, suspected abuse or neglect, or court orders.”

While reasonable efforts are made to protect your information, please be aware that electronic communication (including this form, email, and text) may have risks, including accidental exposure or interception.

By completing this form, you consent to:

The collection, use, and storage of your information for the purpose of providing services from MDRS
Communication via electronic methods such as email, phone, or text as needed for the services.
Understanding the limitations of confidentiality as outlined above.
Check the box below*

I agree to the terms and conditions.
Should be Empty: