Welcome to the Mediation Institute Appointment Request Form
To be completed by participant(s) requesting a mediation session. Complete as much of the information as possible. Once submitted one our mediators will contact you to confirm your request and schedule a time convenient for you.

Your Name

Mailing Address: (will be used to forward your mediation confirmation, directions to our office and and instructions or recommendations for mediation preparation.)

City

State

Zip Code

Telephone Number

Your E-mail Address

What type of case would you like to schedule for mediation?

Family or Divorce

Civil

Commercial

Employment

Please tell us about your case. The information provided is held strictly confidential and is used to help our mediator(s) prepare for your upcoming mediation. All information shared with your mediator or during the mediation sessions is confidential and can not be used in a court of law, nor will the information be shared with any party outside of the mediation room.

Do you have any questions regarding the mediation process, or your upcoming mediation session? Your comfort is important to us, and we will answer any questions you may have prior to your 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.

Guests or Minor Policy: It is The Mediation Institute's Policy that any third parties present in the mediation room must be preapproved by all parties prior to the mediation. Children under 18 should not be a party to any mediation case unless the mediation is a family case where the child is no less than 16 years old and the presence of the child is requested by both parties. An exception to this rule may also be made in sibling to sibling, parent child or peer mediations

* Indicates Response Required

Welcome to the Mediation Institute Appointment Request Form To be completed by participant(s) requesting a mediation session. Complete as much of the information as possible. Once submitted one our mediators will contact you to confirm your request and schedule a time convenient for you.

Welcome to the Mediation Institute Appointment Request Form
To be completed by participant(s) requesting a mediation session. Complete as much of the information as possible. Once submitted one our mediators will contact you to confirm your request and schedule a time convenient for you.