New Mediation Client Intake Form

New Mediation Client Intake Form

Please complete this confidential intake form to help us understand your dispute and determine if mediation is appropriate.
Participant Information (Party A)

Please provide your contact and background information.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Date of Birth (Required for domestic cases involving children)

MonthDayYear
Date
Relationship to Other Party*
Other Party Information (Party B)

Please provide information about the other party if known.
Full Name (Party B)*

First NameLast Name
Address (if known)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number (Party B)
Please enter a valid phone number.
Email Address (Party B)
example@example.com
Is the other party aware you are contacting a mediator?*

YesNo
Legal Representation

Please provide your attorney's information if applicable.
Do you currently have an attorney?*

YesNo
Attorney Name
Law Firm
Attorney Phone Number
Please enter a valid phone number.
Attorney Email Address
example@example.com
Case Information

Tell us about the dispute and court status.
Type of Dispute*

Core Mediation (Neighborhood, community, or small claims)Civil Mediation (Business, employment, or financial disputes)Domestic Mediation (Custody, residency, parenting time, or property division)Parent/Adolescent (Disputes involving parents and children ages 10–18)Juvenile Dependency (Child in Need of Care cases)
Court Status*

Pre-filing (No lawsuit has been filed)Court-Ordered (A judge has ordered mediation)
Case Number (if court-ordered)
County/District (if court-ordered)
Judge (if court-ordered)
Please attach a copy of the Court Order (if applicable)

Cancelof
Brief Description of the Dispute (What are the main issues you hope to resolve?)*
Safety & Screening (Confidential)

This information is confidential and used only for screening and safety.
Is there a current or past Protection from Abuse (PFA) or Protection from Stalking (PFS) order involving these parties?*

YesNo
Do you have any concerns about your physical safety or ability to speak freely during a joint session with the other party?*

YesNo
Are there any special accommodations you require (e.g., separate arrival/departure times, separate rooms)?
Fee Information

Please indicate how payment for mediation will be handled.
How will payment be handled?*

Party A pays 100%Party B pays 100%Shared Equally (50/50)Other
Preliminary Acknowledgments

Please read and acknowledge the following statements.
I understand that the mediator is a neutral person with no decision-making authority.*

I acknowledge
I understand that the mediator cannot give me legal advice.*

I acknowledge
I understand that mediation is a confidential process under K.S.A. 5-512, subject to specific legal exceptions.*

I acknowledge
I understand that I have the right to terminate mediation at any time.*

I acknowledge
Signature*

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Date Signed*

MonthDayYear
Date
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New Mediation Client Intake Form

Participant Information (Party A)

Other Party Information (Party B)

Legal Representation

Case Information

Safety & Screening (Confidential)

Fee Information

Preliminary Acknowledgments