Mediation Intake Form

Name of Party Completing This Form:

Your Name:

First

Last

Your Email:

Your Phone #:

Case Number or Other Identifier (if applicable)

Claim #, CAS#, etc. If none, please indicate N/A or Not Applicable.

Mediation - County:

Mediation - Type:

Mediation - Status:

Estimated Amount in Dispute:

Other Party / Parties Involved in the Dispute:

Contact Information for All Parties (if not already provided)

Please include names, email addresses, and phone numbers for your party and any additional parties involved in the mediation.

How Did You Hear About Our Mediation Services?

Brief Description of the Dispute:

Key Issues You Would Like to Address in Mediation:

What Outcome or Resolution Are You Hoping to Achieve Through This Mediation?

Has Your Party Consulted with or Retained an Attorney Regarding This Matter?

If yes, please provide the attorney's name and phone number.

Have You Previously Participated in Any Form of Alternative Dispute Resolution (ADR), Such as Mediation or Arbitration, Regarding This Matter?

Are There Any Concerns or Special Considerations (e.g., Safety Issues, Sensitive Matters, Language Barriers) the Mediator Should Be Aware of Before the Mediation?

Are the Parties Willing to Participate in a Virtual Mediation Session?

May We Contact You via Text Message? (Please Note: Message and Data Rates May Apply.)

Is There Anything Else You Would Like the Mediator to Know?

1420 Celebration Blvd, Ste. 200 Celebration, FL 34747 | 407-360-9085 | info@givensfirm.com

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