Intake Form

Name

Email Address

Mobile Phone for calling/texting

Are you represented by an attorney? Are you represented by an attorney? Yes No

How would you describe this dispute?

Attorney Contact Information (Optional)

Do you and the other party differ in your current interpretations the problem? Do you and the other party differ in your current interpretations the problem? Yes No

Explain...

Did you discuss your feelings with the other party? Did you discuss your feelings with the other party? Yes No

When?

What do you believe the other party owes you?

Are there any areas where you agree, or are close to agreement?

What are the areas of greatest disagreement?

What are the most important points an agreement must have to satisfy you?

What do you believe are the most important points to the other party?

Are there things the other party might say that would cause you distress or cause you to lose your temper?

If this happens how can I help to keep our discussion on track?

Where you have different ideas on how things should be done, do you have anything to support your belief such as industry standards, notes, receipts, witnesses, photos, etc.?

If we do not arrive at an agreement and you go to court or arbitration: a) What do you think could be your best result?

b) What do you think could be your worst result?

On a scale of 1-5 (with 5 being very important and 1 being not at all important), please rate the importance of the following statements: a) I want an immediate solution even if it is less than I would like On a scale of 1-5 (with 5 being very important and 1 being not at all important), please rate the importance of the following statements: a) I want an immediate solution even if it is less than I would like 1 2 3 4 5

b) I want a big win even if I have to wait a few years b) I want a big win even if I have to wait a few years 1 2 3 4 5

c) I want financial satisfaction c) I want financial satisfaction 1 2 3 4 5

d) I want emotional satisfaction d) I want emotional satisfaction 1 2 3 4 5

e) I want to preserve peace in the relationship e) I want to preserve peace in the relationship 1 2 3 4 5

f) I want to get even f) I want to get even 1 2 3 4 5

What other concerns do you have, even about the mediation process itself?

What do you like to do in your free time?

Do you have a private space where you can have an online meeting without anyone else hearing or watching you? Do you have a private space where you can have an online meeting without anyone else hearing or watching you? Yes No

Do you have your own computer that is private, password-protected, has a camera and a microphone (if not, mobile phone can be used)? Do you have your own computer that is private, password-protected, has a camera and a microphone (if not, mobile phone can be used)? Yes No

Do you need the assistance of anyone else in the room with you while you participate in your mediation online? Do you need the assistance of anyone else in the room with you while you participate in your mediation online? Yes No

Please provide details...

Have you participated in mediation before? Have you participated in mediation before? Yes No

Please provide details...

Have you used Zoom before? Have you used Zoom before? Yes No