Intake Form for Mediation Services (General)

Your Name *

First Name

Last Name

Your Home Phone Number

Country

(###)

###

####

Your Cell Number

Country

(###)

###

####

Your Work Phone Number

Country

(###)

###

####

Your Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Preferred Method of Contact

Home Phone

Cell Phone

Work Phone

Email

Is the Other Party Agreeable to Participate in Mediation? *

Yes

No

Unknown/Have not Discussed

Your Consent to Mediation *

Do you understand that mediation is a completely voluntary process and no one can force you or the other party to participate?

Yes

No

Is this Matter in Court? *

Yes

No

Not currently, but has been in the past

Other Party's Name *

First Name

Last Name

Other Party's Home Phone Number

Country

(###)

###

####

Other Party's Cell Number

Country

(###)

###

####

Other Party's Work Phone Number

Country

(###)

###

####

Other Party's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How Do You and the Other Party Know Each Other? *

Coworkers

Friends

Family/Related

Employer/Employee

Seller/Customer

Neighbours

Landlord/Tenant

Other (please specify below)

Are There Any Legal Reasons/Restrictions in Place that Prevent You From Communicating Directly or Indirectly With the Other Party? *

Yes

No

Are There Any Police Files Relating to this Matter? *

Yes

No

Not Sure/Unknown

Do You Have Any Concerns About Yourself?

Check all that apply

Anger Management

Substance Issues/Addiction

Physical Health

Mental Health and Wellbeing

Capacity to Make Decisions

Fear of Other Party

Safety Concerns If In Presence of the Other Party

Do You Have Any Concerns About the Other Party?

Check all that apply

Anger Management

Substance Issues/Addiction

Physical Health

Mental Health and Wellbeing

Capacity to Make Decisions

Preference for How Mediation Would be Conducted *

Check any that you are comfortable with

In Person

Over Video Conference

Over Telephone (audio only)

Do You Want Us to Send an Invitation to Complete an Intake Form to the Other Party? *

Yes

No