MEDIATION SERVICES INTAKE FORM: FOR LANDLORD/PROPERTY MANAGER
Email address *
PARTICIPANT INFORMATION
Please provide the following information for the person who will be participating in the mediation as the Landlord, Property Manager, or Site Coordinator.
First Name *
Last Name *
Property Name, if applicable
Street Address, Line 1 *
Street Address, Line 2
City *
Zip Code *
Participant Primary Phone Number *
This Phone Is: *
Alternate Phone Number
This Phone Is:
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DEMOGRAPHIC INFORMATION
Gender *
Age Range *
ETHNICITY *
RACE (Check all that apply) *
Required
MEDIATION LOGISTICS
Mediation will be arranged for a single, three-hour session after a preliminary phone call.
Do you have the INTERNET ACCESS, WEBCAM capability, and PRIVACY necessary to participate in a mediation by videoconference? *
Do you have any physical, language, or other accessibility needs to be able to participate in mediation?
NATURE OF DISPUTE
Dispute Resolution Issues (Please check all that apply.) *
Required
If non-payment of rent is an issue in this case, would you accept rental assistance from an outside service provider to help the tenant pay back the balance owed?
Clear selection
Please give additional details about the nature and background of the dispute. Describe any agreements or referrals.
TENANT INFORMATION
Tenant First Name *
Tenant Last Name *
Property Name, if applicable
Street Address, Line 1 *
Street Address, Line 2
City *
Zip Code *
Tenant Phone Number *
Tenant Alternate Phone Number
Tenant Email Address (if known)
Is the tenant aware of and interested in mediation? *
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