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Mediation Intake Form
1. Your Information
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2. Are you submitting this intake as
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2. Are you submitting this intake as
A
An individual
B
On behalf of a business or organization
C
A legal representative
3. Are you one of the parties in the conflict?
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3. Are you one of the parties in the conflict?
A
Yes
B
No
4. Nature of Dispute
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Select the best category for your situation.
4. Nature of Dispute
A
Parent-Child and Siblings
B
Workplace & Management
C
Debt Settlement
D
Landlord/Tenant & Property
E
Intellectual Property
F
Trade and Marketplace
G
Others
5. Brief Description of the Conflict
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6. Desired Outcome
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7. What Do You and the Other Party(Parties) Agree On?
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8. Other Party's Information
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9. Barriers to Resolution
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10. Additional Information
11. Where did you hear about Chatwithamediator.com?
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Submit
