NH Neutral Complaint Form

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* 1. Name

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* 2. Phone number

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* 3. Email Address

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* 4. Case Number

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* 5. Court in which the case took place

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* 6. Name of Neutral

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* 7. Date of Mediation

Date / Time

Date

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* 8. What is the nature of your complaint?

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* 9. Please check one of the following:

I waive confidentiality of the mediation communication to the extent necessary to investigate this complaint.

I do not waive confidentiality. I understand this makes it difficult to investigate the complaint beyond this written record.

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* 10. What is the best way to reach you to discuss this matter? (check all)

Phone

Email

Other (please specify)