Mediation - Party Intake
Civil Matters
Who is completing this form?
*
I am completing this on behalf of myself only (Party A)
We are completing this together as both parties
I am an attorney representing party A
Party A - Information
Please complete this section about yourself (or your client)
Party A: Full Name
*
First Name
Middle Name
Last Name
Party A: Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Party A: Phone Number
*
Format: (000) 000-0000.
Party A: E-Mail
*
Confirmation Email
example@example.com
Does Party A have an attorney?
*
Yes
No
Party A: Attorney information:
Please complete this to best of ability. Leave blank if unknown or N/A
Attorney Name
First Name
Last Name
Firm Name
Party A: Attorney Phone Number
Format: (000) 000-0000.
Party A: Attorney E-mail
example@example.com
Party B: Information
Please fill out to the best of your ability
Party B: Full Name
*
First Name
Middle Name
Last Name
Party B: Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Party B: Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Party B: Email
example@example.com
Does Party B have an attorney?
*
Yes
No
Unsure
Party B: Attorney information:
Please complete this to best of ability. Leave blank if unknown or N/A
Party B: Attorney Name
First Name
Middle Name
Last Name
Party B: Attorney Firm Name
Party B: Attorney Phone Number
Format: (000) 000-0000.
Party B: Attorney E-mail
example@example.com
Would you like us to contact this party to see if they are open to mediation?
*
Yes, please contact them
No, I will reach out to them myself
Please contact me first
How would you like us to contact them?
*
By phone
By email
Both / Either
Have proceedings been filed in court?
*
Yes
No
What county and state have proceedings been filed in?
Example: Oakland County, MI
What is your case number (if known)
Ex: 2025-12345678-DO
What issues need to be mediated?
*
Business / Contract Disputes
Real Estate / Property Issues
Landlord / Tenant Matters
Construction Disagreements
Professional / Partnership Breakups
Consumer / Warranty Claims
Insurance Coverage Disputes
Other
Feel free to expand on any issue
Please do not include personal accusations, legal strategy, or confidential financial details. This form is used only for screening and scheduling.
Would either party prefer to be in separate Zoom rooms
*
Yes
No
Unsure
Which party will pay for the mediation
*
Party A and Party B will evenly split the cost
Party A will pay for both parties
Party B will pay for both parites
Unsure
Other
Please explain
Example 60% Party A 40% Party B
How did you hear of us?
Please Select
Attorney - Party A
Attorney - Party B
Court Referral
Court Website / Resource List
Therapist / Mental Health Professional
I received a letter
Friend or Family member
Former Client Referral
Google Search
Other Social Media
Other
For those with verifiable proof of financial hardship, a reduced rate may be available. Would you like to request a reduced rate because of hardship?
*
Yes
No
I understand that this form is used for initial screening only and that both parties must agree to mediate and sign an official agreement before any session is scheduled
*
Yes
I understand that the mediator, even if licensed as an attorney, is acting solely as a neutral facilitator and not as legal counsel for either party.
*
Yes
PartyAUniqueID
Deal ID
Please verify that you are human
*
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