Community Mediation Intake Form

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Email *

Today's date *

YYYY

I am interested in mediation at Cleveland Mediation Center. Please contact me for an intake appointment.

Name (First & Last): *

How did you hear about our program? *

Briefly describe your situation: *

Gender: *

Date of Birth: *

YYYY

Race: *

Are you hispanic? *

Yes

Annual Household Income: *

Number of people in household: *

Street Address: *

City & State: *

Zip Code: *

Phone Number: *

Email Address:

Best days for you to meet:

Monday

Tuesday

Wednesday

Thursday

Friday

Best time of day to meet:

Name of other party: *

This program is grant funded so there is no charge to the parties.

PLEASE NOTE:
1. This form must be submitted by both parties and received by CMC before appointments are scheduled.
2. We will only re-schedule a mediation session twice before cancelling.

Please read the statements below. *

I understand that not all cases are appropriate for mediation and CMC is not obligated to mediate any case.

By submitting this form I am verifying that the above information is true and complete.

Required

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