This form is strictly confidential and is provided to us as part of a confidential (closed) mediation process. The only exceptions are if a child is at risk of harm, any person is in imminent danger, or a judge orders disclosure of this information. Otherwise, we will not share any of this information without your consent. This information may be used for research or training purposes with all identifying information removed.

IMPORTANT: Each party is required to fill out and submit their own form. Intake forms are needed from both parties to needed proceed with mediation. 

[DISCLAIMER: DESPITE OUR BEST EFFORTS, WE CANNOT GUARANTEE THAT ALL INFORMATION SUBMITTED ELECTRONICALLY IS 100% SECURE AND PRIVATE]

*Please note: it will take you approximately 15 minutes to fill out this form. Please have PDF or JPEG copies of the following documents on hand (if applicable), so you can upload them when prompted: