Please Use this form to request Mediation Works services:

MEDIATING PARTY OR PARTIES

YOUR FULL NAME:

ADDRESS:

PHONE NO.

ATTORNEY REPRESENTING THIS PARTY:

ADDRESS:

PHONE NO.

MAY WE CONTACT THIS ATTORNEY? YES No

OTHER PARTY:

FULL NAME:

ADDRESS:

PHONE NO.

ATTORNEY REPRESENTING THIS PARTY:

ADDRESS:

PHONE NO.

MAY WE CONTACT THIS ATTORNEY? YES No

ISSUES OR PROBLEMS TO RESOLVE:

ARE THERE ANY CHILDREN INVOLVED? IF SO, WHAT ARE THEIR NAMES AND AGES?

1.Name: Age:

2.Name: Age:

3.Name: Age:

4.Name: Age:

IS THIS MATTER PENDING IN COURT?YES No

IF SO, CASE NUMBER:

COURT DIVISION:

COURT DATE: (Please Enter Month Day Year)

IS THIS A POST-DECREE/ DIVORCE MATTER?

HAS MEDIATION BEEN PROPOSED OR ORDERED BY THE COURT?:

MAY WE CONTACT YOU OR THE OTHER PARTY?: YES No

HAVE YOU EVER BEEN INVOLVED IN MEDIATION BEFORE?:YES No

HOW DID YOU HEAR ABOUT MEDIATIONWORKS, LLC.