Mediation Intake Form

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Full Name of Your Party (and any additional parties):

Case # | Other Identifier:

Claim #, SR#, etc. If none, please indicate N/A or Not Applicable.

Mediation - County:

Mediation - Type:

Mediation - Status:

Your Name:

First

Last

Your Email:

Your Phone #:

How did you hear about our mediation services?

Contact Information for All Parties Involved:

Please provide the names, email addresses, and phone numbers of all individuals within the point of contact's party, as well as any other parties involved in the mediation.

Brief Description of the Dispute or Conflict:

What are the key issues you wish to resolve through mediation?

What is your desired outcome or goal for this mediation?

Have any parties involved in the dispute already sought legal advice or been represented by an attorney?

Have you previously participated in any form of alternative dispute resolution (ADR), such as mediation or arbitration?

Do you have any concerns or special considerations (e.g., safety concerns, sensitive issues, language barriers) that the mediator should be aware of before proceeding with the mediation?

Are the parties agreeable to a virtual mediation session?

May we contact you via text? (Please note: Message and data rates may apply).

Is there anything else that you would like to share?

1420 Celebration Blvd, Ste. 200 Celebration, FL 34747 | 407-360-9085 | info@givensfirm.com

The hiring of a lawyer is an important decision that should not be based solely upon advertisements. Before you decide to hire an attorney, ask us to send you free written information about our qualifications and experience. The information at this Site is not, and is not intended to be, legal advice. Neither Erica Givens Glasgow nor The Givens Law Firm, P.A. accepts requests for legal advice nor offer specific legal advice over the internet.