Mediation Intake Form

Date

Please enter today's date.
Case Number
Requesting Party's First Name:

Please enter the Requesting Party's first name.
Requesting Party's Last Name:

Please enter Requesting Party's last name.
Requesting Party's Email:

Please enter your email address.

This isn't a valid email address.
Requesting Party's Phone

This isn't a valid phone number.
Requesting Party's Prior Names (if applicable):
Requesting Party's Attorney Name and Email Address:
Opposing Party's First Name:

Please enter the Opposing Party's first name.
Opposing Party's Last Name:

Please enter Opposing Party's last name.
Opposing Party's Email:

Please enter the Opposing Party's email address.

This isn't a valid email address.
Opposing Party's Phone

This isn't a valid phone number.
Prior Names of Opposing Party (if applicable):
Opposing Party's Attorney Name and Phone Number:
List any past or current affiliation with Rachel A. Michael, LLC

Please enter a message.
What issues are you looking ot Mediate?

Please enter a message.
Desired Mediation Date and Time:
Desired Mediation Date and Time:
Desired Mediation Date and Time:
Have these dates been pre-cleared with the Opposing Party: Yes or No?
Preferred Mediation Location:
Please make a selection.
Physical Limitations of Either Party: