Client Intake Form for Mediation Representation Services

Client Information

  • Full Name: _______________________________
  • Address: _________________________________
  • Phone Number: ____________________________
  • Email Address: ____________________________
  • Preferred Contact Method: __________________

Dispute Information

  • Brief Description of the Dispute:
  • Parties Involved: ___________________________
  • Have you previously attempted mediation or other dispute resolution? (Yes/No) _______
  • Are you currently represented by an attorney outside this service? (Yes/No) _______
  • Do you have full authority to settle the dispute? (Yes/No) _______
  • If no, please explain: ________________________

Payment Agreement

  • I acknowledge that I have received and reviewed the Terms and Conditions and agree to the payment terms outlined.
  • Signature: _______________________________
  • Date: ___________________________________

 

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