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Family Mediation Intake Form

This document 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. It will help us assign the best-suited mediator to your file. It will be read only by the mediator and our staff. IMPORTANT: Each party is required to fill out and submit their own form.

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A PDF version of the Intake Form is available: Intake Form (PDF)

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  • Child's NameAgeChild is Living With 
  • Child's NameAgeChild is Living With 
  • IssueWhy is this important to you? 
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Documents and Forms