HM-002 - Mediation Intake Questionnaire

HM-002 - Mediation Intake Questionnaire
Welcome to Harrington Mediation Client Portal
Document: HM-002 — Mediation Intake Questionnaire

Estimated Completion Time: 10–15 minutes

Thank you for choosing Harrington Mediation.

This questionnaire allows us to better understand your situation before scheduling mediation. Please answer each question as accurately and completely as possible.

Your responses are confidential and will be reviewed only by Harrington Mediation.

Completion of this questionnaire does not establish a mediation relationship or guarantee acceptance of your case. After reviewing your submission, we will contact you regarding the next appropriate step.

Understanding Precedes Resolution.
Participant Information - Please Provide your contact information as you would like it to appear in our records.

First NameLast Name
Email Address
example@example.com
Primary Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact
Preferred Time of Contact
Your Perspective - Please describe, in your own words, what brings you to mediation.
Your Goals - What would you like to accomplish through mediation?
Previous Efforts - Have you attempted to resolve this matter already? If so, what has been tried?
Background Information - Is there anything you believe I should understand before our first meeting?
Participation Considerations - Please select any accommodations or concerns we should be aware of before mediation.

Other
If you selected "Other," please describe.
Scheduling Preferences - Preferred Days
Preferred Times
I certify that the information I have provided is true and accurate to the best of my knowledge. I understand that completion of this questionnaire does not establish a mediation relationship or guarantee acceptance of my case.
Participant Signature
Date

MonthDayYear
Date
Type a question
Should be Empty:

HM-002 - Mediation Intake Questionnaire

Welcome to Harrington Mediation Client Portal