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* 1. Please provide your demographic information below:

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* 2. Please enter the second party's information below:

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* 3. In the space below, please list each issue that needs to be mediated:

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* 4. Please check how you were referred to us:

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* 5. Please select one option below:

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* 6. The best times and days to call you:

  Monday Tuesday Wednesday Thursday Friday Saturday Anyday
Before 9am
Between 9 and Noon
Between Noon and 5
Between 5-9
Between 9-10pm
Anytime
The following questions are optional, however, this information is very useful for us in helping provide you with the best services possible.

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* 7. Have you been through mediation in the past?

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* 8. Do you have an idea as to how many hours it will take to resolve the issues?

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* 9. If you have been to a mediator in the past, please let us know what you found helpful and what you found unhelpful.

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* 10. Please answer true or false for each question below. This helps us understand what you expect from mediation:

  True False
Mediation is legally binding
We discuss issues and the mediator decides for us
Mediators can provide legal advice
Mediators can determine what is in the best interests of a child or children
Mediators can provide financial advice
Mediators are like a judge or referee

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* 11. As best as you can, please tell us what you are looking for in need from a mediator?

T