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MEDIATION SERVICES INTAKE FORM: FOR LANDLORD/PROPERTY MANAGER
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Email
*
Your email
PARTICIPANT INFORMATION
Please provide the following information for the person who will be participating in the mediation as the Landlord, Property Manager, or Site Coordinator.
First Name
*
Your answer
Last Name
*
Your answer
Property Name, if applicable
Your answer
Street Address, Line 1
*
Your answer
Street Address, Line 2
Your answer
City
*
Your answer
Zip Code
*
Your answer
Participant Primary Phone Number
*
Your answer
This Phone Is:
*
Mobile Phone
Home
Office
Alternate Phone Number
Your answer
This Phone Is:
Mobile Phone
Home
Office
Clear selection
DEMOGRAPHIC INFORMATION
Gender
*
Female
Male
Prefer not to say
Other:
Age Range
*
18-24
25-34
35-44
45-54
55-64
65-74
75 years or older
Prefer not to say
ETHNICITY
*
Hispanic, Latino or Spanish Origin
NOT Hispanic, Latino or Spanish Origin
RACE (Check all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Middle Eastern or North African
Native Hawaiian or Other Pacific Islander
White
Multiracial
Other
Required
MEDIATION LOGISTICS
Mediation will be arranged for a single, three-hour session after a preliminary phone call.
Do you have the INTERNET ACCESS, WEBCAM capability, and PRIVACY necessary to participate in a mediation by videoconference?
*
Yes
No
Unsure
Do you have any physical, language, or other accessibility needs to be able to participate in mediation?
Your answer
NATURE OF DISPUTE
Dispute Resolution Issues (Please check all that apply.)
*
Non-payment of rent
Breach of lease
End of lease term
Habitability (Repairs needed)
Other:
Required
If non-payment of rent is an issue in this case, would you accept rental assistance from an outside service provider to help the tenant pay back the balance owed?
Yes
No
Maybe
Clear selection
Please give additional details about the nature and background of the dispute. Describe any agreements or referrals.
Your answer
Has there already been a court filing with the magistrate for this dispute?
*
Yes
No
Unsure
Is this a unit subsidized through Section 8, a project-based voucher, or other types of public assistance? If your answer is YES, please specify.
Your answer
TENANT INFORMATION
Tenant First Name
*
Your answer
Tenant Last Name
*
Your answer
Property Name, if applicable
Your answer
Street Address, Line 1
*
Your answer
Street Address, Line 2
Your answer
City
*
Your answer
Zip Code
*
Your answer
Tenant Phone Number
*
Your answer
Tenant Alternate Phone Number
Your answer
Tenant Email Address (if known)
Your answer
Is the tenant aware of and interested in mediation?
*
Yes
No
I don't know.
How did you hear about us?
Your answer
Send me a copy of my responses.
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