Mediation Intake Form

Name

Number

Email Address

Attorney (if represented)

Attorney's Number

Attorney's Email

Case Information: Name

Case Number

Presiding Official

Relevant Timeline - Last Hearing

Relevant Timeline - Next Hearing

Other Timeline

Nature of Case

Is this mediation Court ordered? Is this mediation Court ordered? Yes No

Have you attempted mediation prior? Have you attempted mediation prior? Yes No

Value of assets/estate $

For Mediation: Preference- For Mediation: Preference- In Person Virtual No Preference

What are your goals for mediation?

Are there any things in particular you are concerned about?

What are certain aspects of the case you are willing to consider negotiating about?

Are there any aspects of the case you would prefer not to negotiate?

Please use the following space for any additional information you would like the mediators to know: