Mediation Intake Form
A simple worksheet to collect key information about your dispute before your mediation session.
Mediation Intake Form
A simple worksheet to collect key information about your dispute before your mediation session.
You can use this form to prepare for your mediation. Fill it out and share it with the mediator before your session, or simply use it as a guide for the information you’ll need.
You can print this page or save it as a PDF for your records.
Participant information
Name: _______________________________
Phone: _______________________________
Email: ________________________________
Preferred contact method: ______________________
Other party (or parties)
Name(s): ______________________________
Relationship to you: _____________________
Attorney (if any)
Name: ________________________________
Phone / Email: _________________________
Type of dispute
☐ Real estate
☐ Business / contract
☐ HOA / community
☐ Workplace / partnership
☐ Other: _____________________________
Background summary
Briefly describe what happened and how the dispute started:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Key issues to resolve
1. _____________________________________________________________________________________________________________
2. _____________________________________________________________________________________________________________
3. _____________________________________________________________________________________________________________
Your goals in mediation
What would a good outcome look like for you?
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Important dates / deadlines
(Court dates, contract deadlines, move-out dates, etc.)
_______________________________________________________________________________________________________________
Documents you have
☐ Contracts / agreements
☐ Emails / letters
☐ Notices / legal paperwork
☐ Other: _____________________________
Other information you want the mediator to know
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
You can use this form to prepare for your mediation. Fill it out and share it with the mediator before your session, or simply use it as a guide for the information you’ll need.
You can print this page or save it as a PDF for your records.
Participant information
Name: _______________________________
Phone: _______________________________
Email: ________________________________
Preferred contact method: ______________________
Other party (or parties)
Name(s): ______________________________
Relationship to you: _____________________
Attorney (if any)
Name: ________________________________
Phone / Email: _________________________
Type of dispute
☐ Real estate
☐ Business / contract
☐ HOA / community
☐ Workplace / partnership
☐ Other: _____________________________
Background summary
Briefly describe what happened and how the dispute started:
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Key issues to resolve
1. ______________________________________________________________________________________________________________________________
2. ______________________________________________________________________________________________________________________________
3. ______________________________________________________________________________________________________________________________
Your goals in mediation
What would a good outcome look like for you?
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Important dates / deadlines
(Court dates, contract deadlines, move-out dates, etc.)
______________________________________________________________________________________________________________________________
Documents you have
☐ Contracts / agreements
☐ Emails / letters
☐ Notices / legal paperwork
☐ Other: _____________________________
Other information you want the mediator to know
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Ready to move forward with your mediation?
If you’d like help with this form or want to talk through your situation, we’re here to help.
Ready to move forward with your mediation?
If you’d like help with this form or want to talk through your situation, we’re here to help.
Guiding conversations. Building understanding.
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Professional mediation serving Long Beach and all of Southern California.