Family Mediation Intake Form (non-divorce)

This form is used to request mediation for a family dispute that is not related to a pending divorce. Disputes such as parent/child disputes, disputes between spouses, disputes between siblings and many other issues may be considered family disputes. For a more complete list of what is covered under this type of mediation, see the "Type of Dispute" box below.

Preferred Mediation Date:

Preferred Mediation Date: :: Please enter a date that corresponds with an available date on our calendar.

1st Optional Date:

1st Optional Date: :: Please select an additional date that corresponds with an available date on our calendar.

2nd Optional Date:

2nd Optional Date: :: Please select one more date that corresponds with an available date on our calendar.

Preferred Session:

Preferred Session: :: Please enter the length of time that you believe it will take to complete the mediation. Additional time may be scheduled as needed.

If half-day requested, is there a preferred start time?

If half-day requested, is there a preferred start time? :: Please select the time of day that you prefer the mediation to start.

Have the selected dates been confirmed by all the parties?

Yes
No
Don't Know

General Dispute Information

Please select the type of dispute:

Please provide a brief description of your dispute here:

Contested Amount:

Contested Amount: :: How much money is at stake in the dispute? If none, then enter "0". Must be entered in 0.00 format.

Court Information

Case name or Style No.:

Cause No. (if any):

Court (if any):

Court (if any): :: Please enter the name or designation of the court where you suit has been filed.

Personal Information

What is your position in this dispute?

First Name:

Last Name:

Mailing Address:

Mailing Address: :: Please be sure you enter the address where you will want to receive documents or other information pertinent to your case.

Primary Telephone #:

Secondary Telephone #:

Email Address:

Attorney Information

Have you retained the services of an attorney or law firm?

Yes
No

Attorney's Name (if known):

Law Firm (if any)

Attorney/Law Firm Phone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

Additional Parties Involved

Please enter the full names and contact information of all additional parties involved in this dispute:

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Resources

Resources for Court Officials

For more information about conflict management or to schedule a mediation, please give us a call at:

(469) 293-4237

We are available 24 hours a day to assist you with your dispute resolution needs!