Mediation Services Intake Form
Please complete this intake to help us understand your mediation needs. All information is confidential.
Contact Information
Tell us how to reach you and your role in the dispute.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Preferred Contact Method
*
Email
Phone
Text
Role in Dispute
*
Party A
Party B
Legal Representative
Dispute Category
Help us understand the context of your situation.
Please select the area that best describes your situation:
*
Workplace Conflict (Issues between colleagues or departments that don't necessarily involve formal HR grievances yet.)
Employee Disputes (Specific conflicts regarding employment terms, performance reviews, or termination.)
Community Dispute Resolution (Issues involving neighbors, local organizations, or community groups — e.g., noise complaints, property boundaries.)
Contract Disputes (Disagreements over the interpretation or fulfillment of a signed agreement.)
Business Dispute Resolution (Conflicts between partners, vendors, or separate business entities.)
Resolution Planning (Proactive mediation to help parties design a path forward before a conflict escalates.)
Case Overview
Details about your dispute and parties involved.
Briefly describe the nature of the dispute:
*
Who are the other parties involved? (Names and contact info if available)
Is there any pending litigation or upcoming court dates?
*
Yes
No
If yes, please provide the date:
-
Month
-
Day
Year
Date
Goals and Readiness
Share your objectives and previous resolution attempts.
What is your primary goal for this mediation? (e.g., Financial settlement, restored working relationship, contract clarification)
*
Have you previously attempted to resolve this through other means?
Direct negotiation
HR intervention
Legal counsel
None
Are all parties willing to participate in a good-faith mediation session?
*
Yes
No
Unsure
Conflict Dynamics Diagram
Reflect on the nature of the conflict.
Which of these feels most stuck for you right now? (Interests, Rights, Power)
Logistics
Meeting preferences and urgency.
Preferred Meeting Format
*
In-person
Virtual (Zoom/Teams)
Hybrid
Urgency
*
Low
Medium
High (Needs resolution within 14 days)
Information provided in this intake form is used solely for the purpose of evaluating your case for mediation. Mediation is a voluntary and confidential process.
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