Intake Form

This questionnaire should take approximately 10–15 minutes to complete. Please answer as many questions as you can to the best of your ability. If possible, have the other party involved complete this questionnaire as well, as this will help us serve you more efficiently. We require a name and contact information for each party in order to proceed. We aim to respond within two business days; however, please note that scheduling your mediation may take up to eight weeks. Thank you.

Your Contact information

Name
Pronouns
Address

Your Demographics

As a nonprofit, the Mediation Center needs to collect demographic information of its clientele for grants and other reports. Your information will be aggregated with all respondents and not linked to you personally.

If you are an attorney filling out this form on behalf of your clients, please enter your client's information.

Annual Household Income
Annual Personal Income

Your Dispute

Please provide information about the dispute you would like mediated.

Is there a Temporary Restraining Order (TRO) in place regarding this dispute or Order of Protection in place regarding this dispute?
format of the date must be mm/dd/yyyy
Maximum of 250 characters. Currently used: 0 characters.
Maximum of 250 characters. Currently used: characters.
Availability

Other Participant(s)

Please provide the contact information for the other party. You must provide their phone number and/or their email.

Lead Other Participant's Name
May we contact the other party?
Other Participant Address
Do you need an interpreter?

Mediation Process

I have the appropriate equipment, as listed above, to participate in Zoom mediation
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