Mediation Request Form

In order to initiate the scheduling process, fill out this form as completely as possible. Cases will be scheduled in the order they are received.

Your Contact information

Name*

Pronouns*

He/Him

She/Her

They/Them

Ze/Hir(Zir)

Prefer not to say

Address*

Street Address

Address Line 2

City

State

Zip Code

Country

Phone Number*

Email*

Attorney, if you have one

Attorney's Email

Attorney's Phone

I was referred by*

Your Dispute

Please provide information about the dispute you would like mediated.

Case Type*

If this dispute is related to a court case, please provide the Case Number

Return to Court Date

Issues/Concerns to be mediated* Maximum of 250 characters. Currently used: 0 characters.

Availability*

Mornings (9am) Monday - Friday

Afternoons (1pm) Monday - Friday

Other Participant(s)

Please provide the contact information of the other person(s) in this dispute. You must provide their phone number and/or their email.

Other Participant's Name*

Other Participant's Phone Number*

Other Participant's Email*

If there are more people participating in this mediation, please list their names, contact information, and their relationship to the dispute

Your Demographics

As a nonprofit, the Mediation Center of the Pacific needs to collect demographic information of its clientele for grants and other reports. Your information will be aggregated with all respondents and not linked to you personally.

If you are an attorney filling out this form on behalf of your clients, please enter your client's information.

Ethnic Background

Age*

Do you need an interpreter?*

Yes

Employment Type

Number of People in Household*

Annual Household Income*

Annual Personal Income

Accommodation Requested