Mediation Intake Form

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Name *

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Email *

Cell Phone Number *

Preferred Contact Method

Case Type *

Is there a temporary or permanent order connected to this matter? *

Is there a scheduled court date for this matter? *

What issues would you like to mediate? *

Number of Parties (including yourself) *

Do all parties agree to mediate? *

schedule Method violence

Are there any safety concerns, incidents of harrasment or domestic violence connected to this matter? *

Best times to schedule mediation (check all that apply)

How did you hear about Nixson Mediation?