Community Mediation Services

Intake Form

Upon completion of this confidential form, a mediator will be assigned to your case and will contact you to schedule an orientation meeting.

Question Title

* 1. Claimant Information (person requesting information)

Name *

Company

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 2. Relationship to party in this matter

Self

Attorney for party

Other (please specify)

Question Title

* 3. Case Type

Landlord/Tenant

Neighbor/Neighbor

Consumer/Merchant

Homeowner Association

School/Family

Creditor/Debtor

Employment

Accident

Family/Domestic

Other (please specify)

Question Title

* 4. Referral Source

LA County DRPA Providers website

Self referral

Former client

Police

Other Public Agency

Presentation

Internet Search

Other (please specify)

Question Title

* 5. Respondent (other party)

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 6. Briefly describe what you hope to accomplish through mediation:

Question Title

* 7. Is there a court case associated with this conflict?

Yes (please enter case number):

Question Title

* 8. Are you or the other party represented by an attorney?

Yes