Mediation Request Form
Please fill out the field below to request mediation

Personal Information

Name *
First Name
Middle
Last Name
Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Daytime Phone
Evening Phone
Email Address
Referred By
Employer
Occupation

 

 

Describe any significant health issues that might impair your ability to effectively participate in mediation:
If you have received advice from anyone else regarding this situation, please describe:

 

 

 

 

Religious Background

Religion
Do you believe in God?
How often do you pray to God?
How often to you read or study your Bible?
What is your view on the authority of Scripture?
Please gives names and relationships of those who have the most influence on your spiritual life:

 

Other Person in Conflict

Name
First Name
Middle
Last Name
Relationship
Length of Relationship
Employer
Occupation
Attorney
Date
Age
Marital Status
Married Years
Separated Years
Spouse's Name and Age
Names and Ages of Children

 

Attorney's Name (if you have one)
First Name
Middle
Last Name
Attorney's Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
If legal action has been filed or is likely to be filed, please describe:

 

What church do you attend?
How often do you attend church?
Church Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Church Phone
Pastor's Name
Church leadership roles or activities you are involved in:

 

 

Address
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Daytime Phone
Evening Phone
Email Address
Church
This person's religious orientation and commitment

Information on Your Problem or Dispute

Briefly describe your problem or dispute (you can provide more information in your interview later)
What have you done to resolve this problem or dispute?
What issues or questions do you want to have answered or resolved?
What do you want us to do?
If this is a legal issue, what are you asking for (include dollar amount, if any)?
Other information we should know?