College Houses: Mediation Request/Intake Form
Email address *
Membership mediation is not a conduct/disciplinary procedure. Grievances or allegations that may arise in mediation will not be considered a formal report of conduct unless participants reveal anything about an intent to seriously harm themselves or someone else. If you want to report a behavioral, conduct, or disciplinary concern, please use the College Houses Incident Report Form. *
Membership mediation is not a substitute for therapeutic treatment with a licensed mental health practitioner. If a conflict situation is impacting your mental health, then College Houses requests that you seek support from a licensed mental health practitioner. If you have been diagnosed with panic attacks, obsessive-compulsive disorder, depression, schizophrenia, bipolar or manic depression, post traumatic stress syndrome, or borderline personality disorder, College Houses requests that you discuss the mediation process with your mental health provider before you begin the process. If at any time you are in crisis or become a threat to yourself or others, your first point of contact should be emergency services by calling 911. *
Full Name *
Your answer
House *
Phone Number *
Your answer
The Role of the Mediator
When the Membership Director acts in the role of mediator, they attempt to help parties in a disagreement to hear one another, minimize the harm that can come from disagreement (e.g. hostility or defensiveness), maximize any area of agreement, and find a way of preventing the areas of disagreement from interfering with the process of seeking a compromise or mutually agreed outcome. Effective mediation requires a balance of power and a level of willingness to find a way forward together that all parties can live with. If the mediator has reason to believe that one or both of the parties is not engaging in the process in good faith or is not working towards constructive outcomes, the mediation may be terminated by the mediator. For this reason, before engaging in the process, members seeking mediation are advised to schedule individual appointments with the Membership Director and realistically assess the viability of mediation as opposed to other tools/resources for addressing relationship dynamics or conduct. Mediated discussions remain private; the only exceptions usually involve child or elder abuse, actual or threatened criminal acts, or indications that the member is a danger to themselves and/or others. Please type your initials below to indicate your acceptance of these terms. *
Your answer
Timeframe for mediation
After submitting this intake form, the remainder of the process is scoped to take place over the course of a single, 2-3 hour, in-person meeting (though time may vary by situation and may be split into two, 1-1.5 hour meetings).

The agreement to, scheduling, and completion of mediation processes typically takes up to 2-4 weeks, as in-person mediations require schedule coordination among several parties. Additionally, the Membership Director is on call for resident emergencies, conduct report review, and legal document preparation; these priorities may affect scheduling availability for mediation support.

Confirm understanding of timeframe:
Definition of Narrative Mediation:
Conflict can be described as a mismatch of expectations between what you thought should happen and what in turn actually happens. The Narrative Mediator empowers parties in conflict to identify and surface those unsaid expectations to improve understanding, increase mutual respect and dilute the conflict-saturated stories that dominate the narratives of parties in conflict. Parties learn conflict resolution and communication techniques and tools that help them to create a new, richer, co-created narrative that helps establish shared understandings and build trust, recognition, and respect.
(Definition adapted from Dr. Gerald Monk, a Professor in the Department of Counseling and School Psychology at San Diego State University's Marriage and Family Therapy Program)
Narrative Mediation Protocol
Mediator's Goals:
• To provide a high-level distilled analysis that moves the parties from stories to solutions.
• To facilitate an empowering process by which the mediator fosters empathy, insight, and recognition in all parties.
• To provide the parties with equitable time to tell their sides of the stories and be heard by the mediator and other party/parties without judgement.
• To teach parties to recognize and honor the legitimacy of different perspectives and listen actively.
• To challenge parties to shift out of entrenched positions of “suffering” or “right/wrong” and into curiosity, fluidity, presence, and a results-focused orientation.
• To distill the core shared narrative to a pared-down version all parties can live with.
• To invite the parties via this exercise to employ active detachment and release all aspects of the story (especially and including stuck and stored emotions) that are not conducive to their health and optimal future/realization of their goals/vision.
Mediation Ground Rules
1. We agree to take turns speaking and not interrupt each other.
2. We agree to call each other by our first names, not "he," "she," or “they.”
3. We agree to not blame, attack, or engage in put-downs and will ask questions of each other for the purposes of gaining clarity and understanding.
4. We agree to stay away from establishing hard positions and express ourselves in terms of our personal needs and interests and the outcomes that we wish to realize.
5. We agree to listen respectfully and sincerely try to understand the other person's needs and interests.
6. We recognize that, even if we do not agree with it, each of us is entitled to our own perspective.
7. We will not dwell on things that did not work in the past, but instead will focus on the future we would like to create.
8. We agree to make a conscious, sincere effort to refrain from unproductive arguing, venting, or narration, and agree to use our time to work toward what we perceive to be our fairest and most constructive agreement possible.
9. We will disclose if something is not working for us.
10. We will request a break from dialogue when we need to.
12. We will point out if we feel the mediator is not being impartial as to person and neutral as to result.
• Willingness, desire, commitment, participation, and preparation.
• Respect for ground rules.
I understand, and I meet the requisites listed above. I am willing to try narrative mediations as a tool. *
I understand that narrative mediation is a consent-based practice: I understand I have the right to terminate the narrative mediation process at any time, and the same is true for the other party/parties and the mediator. *
I understand that the only result of mediation is the good-faith consensual agreements developed between the parties. Any mediated agreements do not reflect commitments to College Houses, and College Houses is not expected to uphold or enforce any agreements reached between the parties in mediation. *
Mediation Preparation: Intake
Please describe the conflict(s) that bring you to mediation: *
Your answer
What are your goals for this integrated negotiation/mediation? *
Your answer
Are you the person who is initiating this negotiation? *
Are you in a position where you can make decisions regarding the outcome(s)? *
On a scale of 1 to 10 (10 being the highest), how much DESIRE do you have to improve the relationship(s) and move forward in a way that works for everyone? * *
Strong Opposition
Strong Desire
On a scale of 1 to 10 (10 being the highest), how much DESIRE do you feel that the other party/parties have to do their part to improve the relationship(s) and move forward in a way that works for everyone? *
Strong Opposition
Strong Desire
On a scale of 1 to 10 (10 being the highest), how COMMITTED are you to doing your part to improve the relationship/s and move forward in a way that works for everyone? *
Very Opposed
Very Commited
On a scale of 1 to 10 (10 being the highest), how COMMITTED do you feel that the other party/parties are to doing his/her/their part to improve the relationship/s and move forward in a way that works for everyone? *
Very Opposed
Very Committed
On a scale of 1 to 10 (10 being the highest), how capable do you feel of making solid, realistic decisions that are in your best interests right now? *
Not Capable
Very Capable
On a scale of 1 to 10 (10 being the highest), how capable do you feel the other party/parties to make solid, realistic decisions that will work for all involved right now? *
Not Capable
Very Capable
Do you feel ready, willing, and able to work towards win/win solutions with the party/parties you have listed above? *
Please elaborate why you feel or do not feel ready, willing, and able to engage in results-oriented negotiation with the person/people listed above. *
Your answer
Have you engaged in previous mediation, counseling, or coaching with the involved party/parties? *
If stress plays a role in the relationship, is the source of stress known?
Mediation Preparation: Personal Reflection
What are the things that you value deeply? Specifically, the things you value about yourself, your relationships, your life, your work? *
Your answer
Yourself: Without being humble, what do you value most about yourself, as a human being, a friend, a student, an employee, etc.? *
Your answer
Your relationships: When you are feeling the best about your relationships, what do you value about them? What does it feel like? *
Your answer
What do you love? *
Your answer
Core value: What do you think is your core value? *
Your answer
What do you really want in life? If you had three wishes, what would they be? *
Your answer
How do you see yourself moving forward in your goals? *
Your answer
Is there anything that limits you from taking action? If so, what do you think it is?
Your answer
Are you willing to trust yourself, have courage, and take action? *
How will your life be different when you reach your goals? *
Your answer
Please use the space below to share any other pertinent information:
Your answer
Mediation Preparation: Proposed Agenda
Appreciation and Visioning:
You will be asked to share YOUR levels of desire and commitment to improve the relationship(s) and move forward in a way that works for everyone.
You will be asked to write down a list of things you like and respect about one another and share it.
You will be asked to co-create a vision for how things will be on the other side of this process.

Participant Needs/Wants:
You will be asked to think about your relationship dynamics and the tensions that have brought you to mediation.
This exercise will include listing what the other party should or should not do or have done. DO NOT SHARE THIS LIST WITH THE OTHER PARTY BEFORE THE MEDIATION. It is essential to maintain goodwill and keep things safe and positive. We will use your pre-work to engage in positive and pragmatic negotiation.

Participants will develop agreements, do some reality testing, and develop a plan of action.

Participants may elect to schedule check-ins or request additional mediations to update or revise their agreements.

Confirm Understanding of Next Steps: *
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