Start Mediation: Intake Form

Fill out the form below to begin the process of resolving your dispute.
When you submit the form an email is sent to us. We consider this communication to be private and confidential.

Thank you.

Please fill out your basic information:
First Name:
 (Required)
Last Name:
 (R)
Phone:
 
Email:
 (R)
Business Name
(if applicable):
  

If you do not wish for the mediator to contact the other party please leave this section blank.

Please fill out the other party's basic information:
First Name:
Last Name:
Phone:
 
Email:
Business Name
(if applicable):
  

Are there other parties involved in this dispute?
If so, list email addresses of other parties (one per line):

Please fill out these dispute details:
Nature of the dispute:
What date did this dispute begin?
What is the approximate monetary value of the items under dispute?
This dispute is regarding...
 (R)
What do you and the other party disagree about?
 (R)
Are there any things you and the other party might agree upon?

What has happened so far in this dispute? (phone calls, emails, etc.)
What do you want to get from this mediation?
 (R)
Please add anything else you think it would be helpful for a mediator to know:

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John Ford and Associates
Workplace Conflict Management Services
81 Echo Avenue, Oakland, Ca 94611
(510) 658-5524 Fax 594-1728
"Helping you prevent, manage and resolve workplace conflict"

©John Ford 2000