Mediation Intake Form
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Please use this form to communicate with us that you are interested in learning about mediation for your situation. Fill out this form to get started, as much as you can. There is no obligation until I have spoken with all participants and determined that we are to be your mediator. If I have not yet communicated with the other party(ies), I will do so before we confirm the mediation. 

If your mediation is for family matters (Separation/Divorce/Parenting), please use this form instead: https://forms.gle/EjeWeBud581jeXuQA

If you are the attorney for this participant, please provide all participant information and provide your own information afterwards.
What is your name? *
What is your email address?
What is your phone number?
In which state US state does this participant reside? Is the other participant in another state? Please provide details.
Please give your attorney's name, number, and email address if applicable:
What is the other participant's name?
What is the other participant's phone number?
What is the other participant's email address?
Does the other participant have an attorney? If so, please provide their name, number, and email address:
Does the other participant (or their attorney) know that you are seeking a mediator in this matter?
Clear selection
Will the other participant be willing to mediate?
Clear selection
What are the issues to be resolved in mediation? *
Please provide as much additional detail as you wish on any of the above questions:
Mediation Scope and Disclaimer
No legal advice is given during any part of the mediation process.

A mediator can assist you in coming to an agreement with the other participant(s) about certain aspects of your situation. A mediator can not provide any legal advice. The agreement reached by the participants will be written up and signed by all the necessary people. The mediator can not represent you in court. With respect to any legal paperwork that may have to be filed to ensure that the results of your agreement are properly implemented, we highly recommend that you obtain the services of at least one lawyer to help you put everything together.

Having said that, many cases involve the use of a mediator and it is mandatory in some states to use a mediator if you cannot come to an agreement on your own. This statement is written for the purpose of explaining to you about the limits of a mediator's role.
Please write your full name in here to show that you understand and agree to the above statement: *
Thank you for your responses.  
Did you provide either a phone number or an email address, or both?  If so, I will contact you promptly. I look forward to working with you! Now please PRESS the SUBMIT button below!
Anthony Matthews, Mediator (720) 744-2689
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