Mediation Intake Form

Date

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Case Number
Petitioner's First Name:

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Petitioner's Last Name:

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Petitioner's Email:

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Petitioner's Phone

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Prior Names of Petitioner:
Petitioner Attorney Name and Phone Number:
Co-Petitioner/Respondent's First Name:

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Co-Petitioner/Respondent's Last Name:

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Co-Petitioner/Respondent's Email:

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Co-Petitioner/Respondent Phone

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Prior Names of Co-Petitioner/Respondent:
Co-Petitioner/Respondent Attorney Name and Phone Number:
List any past or current affiliation with Rachel A. Michael, LLC

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What issues are you looking ot Mediate?

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Desired Mediation Date and Time: