Civil Mediation Intake Form - Individuals

This form is for non-commercial disputes involving individuals (not divorce or family related). Please complete this form as thoroughly as possible. Use "N/A" if something is not applicable. Use "Don't Know" if you are unsure of the answer.

Preferred Mediation Date:

1st Optional Date:

2nd Optional Date:

Preferred Session

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

Have selected dates been confirmed by all the parties?

Yes
No
Don't Know

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? Must be entered in 00.00 format.

Case Name or Style No.:

Cause No. (if any):

Court (if any):

YOUR PERSONAL INFORMATION

What is your position in this dispute?

First Name

Last Name:

Mailing Address:

Primary Telephone #:

Secondary Telephone #:

Email Address:

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

2ND PARTY INVOLVED IN THE DISPUTE

2nd Party's position in this dispute:

2nd Party's Full Name:

2nd Party's Mailing Address:

2nd Party's Telephone Number:

2nd Party's Email Address:

Attorney's Name (if any):

Law Firm (if any):

Attorney/Law Firm Telephone #:

Attorney/Law Firm Fax #:

Attorney's Email Address:

ADDITIONAL PARTIES

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

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!