Mediation Request Form
Please complete all available and applicable information.

Any questions, please contact us by phone at (843) 972-3683 or 
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Email *
Requester's Name *
Requester's telephone *
Today's Date
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DD
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YYYY
Are you the: *
Referring Agency or Organization (if any)
Case Number and Name (if not applicable, indicate N/A)
Type of Case *
Claimant/Plaintiff Information- Name, address, phone, email (if same as requester, indicate "same"; if unknown or not fully known, enter available information) *
Respondent/Defendant Information - Name, address, phone, email (if same as requester, indicate "same"; if unknown or not fully known, enter any available information) *
Claimant/Plaintiff Attorney Information - Name, address, phone, email.  If none, indicate N/A.  (If same as requester, indicate "same", if unknown or not fully known, enter any available information) *
Respondent/Defendant Attorney Information - Name, address, phone, email.  If none, indicate N/A.  (If same as requester, indicate "same"; if unknown or not fully known, enter any available information) *
GAL. If a family or probate case, indicate if Guardian ad Litem (GAL) has been appointed and provide name and contact information.
Claimant/Plaintiff Financial Information (Income and Cash Assets) - An updated financial declaration is required to be submitted to MMCC to determine fee level. For bankruptcy cases, please email Schedule I or J.  Please email all forms to administrator@mediationcentercharleston.org. *
Respondent/Defendant Financial Information (Income and Cash Assets) -  An updated financial declaration is required to be submitted to MMCC to determine fee level.  Please email all forms to administrator@mediationcentercharleston.org. *
Summary of Contested Issues *
Special Needs or Requests. Any special needs or requests regarding the mediation (location, interpretation, etc.), please indicate below.
Scheduling. How far out would you like to schedule the mediation?  Check all that options that would work for you from today's date (date of filing the request). *
Required
Scheduling. Is there a court ordered deadline for this mediation?  
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Preferred Mediation Dates/Times (check all that apply)
9:30 am - 1:00pm
1:00 pm - 4:30pm
Full Day 9:30 am - 5 pm
Mon
Tue
Wed
Thu
Fri
Preference for mediation (click all that apply): *
Required
Administrative Fee.  An upfront administrative fee payment of $25 per party, regardless of income, is due to upfront to ensure participation of both parties and to initiate scheduling the mediation.  Payment can be made at:  https://www.mediationcentercharleston.org/product/pro-bono-low-bono-filing-fee/.  

By selecting 'Yes', I understand and will comply with the terms above. 
 *
Required
Mediation Fees.   Mediation fees are assessed in accordance with the MMCC fee schedule and due at within 7 days of scheduling mediation time/date or 48 hours prior to scheduled mediation, whichever is sooner.  Details on our fee schedule can be found at: https://www.mediationcentercharleston.org/request-mediation-services/ including our cancellation policy. 

By selecting 'Yes', I understand and will comply with the terms above. 
 *
Required
Case Documents, Financial Declarations and Confidential Mediation Statement.  MMCC Requests any and all such information at least 72 hours prior to the start of the scheduled mediation time/date. Please email directly to MMCC at:  administrator@mediationcentercharleston.org. All information will be collected and shared in full confidence with the mediator.  

By selecting 'Yes', I understand and will comply with the terms above. 
 *
Required
THANK YOU FOR REACHING OUT TO MMCC AND ALLOWING US TO BE OF SERVICE TO YOU!
A copy of your responses will be emailed to the address you provided.
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