Community Care Mediation Intake Form
Community Care Mediation creates spaces where participants feel comfortable sharing grievances with one another, where the fear of conflict escalating towards punitive justice is replaced by a culture of seeing conflict as an opportunity for greater understanding. Our role as facilitators and mediators is to be responsible for holding the process, while participants will be responsible for any outcomes. 

In our practice, we want to be clear that:

- Mediation is voluntary - All parties must choose to participate in the mediation willingly
- Mediation is not legally binding - Though we have experience and training, we are NOT lawyers and agreements will NOT be legally binding
- Mediation takes time - From initial outreach to concluding a mediation session, the process can take several weeks

Use this form to let us know what support you need at this moment and we’ll get back to you soon. Thank you!
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Email *
Your Name *
Preferred phone number *
Email
City
Pronoun(s) *
Required
How did you hear about Community Care Mediation? 
Please give us a brief description of your conflict. A member of our team will call you to follow up for more information and to complete your intake.  *
When we contact you, do you prefer to talk over the phone, or a zoom video-conference? *
What days/times work best for you to talk with us?
Are there any other needs you have in order to have this process be more accessible to you? (e.g. Food, Transportation, Written Documentation, Interpretation)
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