Case Referral - Mediation Services
To be completed by the requesting attorney's office. Complete as much of the information as possible. Once submitted one our mediators will contact your office to confirm the request and schedule a time convenient for all parties attending the mediation session. With multiple mediators on staff we are capable of accepting mediation sessions on a reasonably short notice. If you have an urgency or court order and need a scheduling confirmation immediately please feel free to contact one of our mediators now, (918) 877-1427, or 1-877-Why-Dispute.

* Why type of case would you like to refer for mediation?

How were you referred to The Mediation Institute?

Referred by Colleague

Returning Client

Will attorneys be present to represent the mediating parties?

Yes, both parties to be represented

At least one party represented

Represented but unable to attend

Is this mediation court ordered?

Yes

No

* When are the parties scheduled to return to court court?

Attorney's Name or Firm

Office Number

Who should we contact in your office for scheduling?

Your E-mail Address

Party # 1 - The first party's name and contact information.

Party #2- Second party's attorney, name and contact information.

Please give us a short summary of the case.

* What issues should be addressed in this mediation session?

* Is there a Protective Order in place?

Yes

No

In Process

Who does the Protective Order Involve?

Spouse

Minor Child/Children

Spouse and Minor Children

Other

Any additional information you feel is important for the mediator to know regarding the mediation or the parties involved? Are there documents, financial or legal, that may assist the mediators during the meeting?

We look forward to servicing your client and seeing you in our upcoming session.

Payment Options: Payment for mediation services is due at the time of service. To make our services convenient to all participants, we accept the following forms of payment on or before the day of service: Visa, Mastercard, Money Order, Cash or Certified Check.

Travel to outlying areas is available with notice.

* Indicates Response Required