Intake Questionnaire - Humboldt Mediation Services
To help us begin work on your case, please provide the following information. Please check all that apply for each multiple choice question. Most of the questions will be very quick answers. Don't feel pressured to answer in great detail; you'll be able to give information in greater depth during your case development meeting.
Please type your name. (If you would prefer a greater degree of online confidentiality, please call our office at 707-445-2505 Mondays through Thursdays, 10 a.m. to 2 p.m. to receive a file number to type here instead of your name.) *
Your answer
Please type a phone number or email address. *
Your answer
How did you hear about Humboldt Mediation Services?
How long has this conflict existed?
What other steps have you taken to try to resolve this conflict?
Is mediation an alternative to court for you?
If you are unable to reach a voluntary agreement through mediation, what will your next step be?
During this conflict, has there been violence or threat(s) of violence?
If there has been violence or threat(s) of violence, please explain:
Your answer
If there has been violence, was it reported?
If violence was reported, to whom was it reported?
Your answer
Will you need accommodation at the mediation session?
If you need an interpreter, in what language? Please note we'll do our best to provide language assistance.
Your answer
What do you hope to achieve through mediation?
Your answer
What times/days of the week are best for you to meet?
8 a.m. to noon
noon to 5 p.m.
After 5 p.m.
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What other information would help us better handle your case?
Your answer
For divorce/separation and/or co-parenting issues, please also answer the following:
Do you have minor children?
If yes, what are their ages:
Your answer
How long have you been married and/or partnered?
Your answer
Were you legally married?
Are you currently separated?
If separated, how long have you been separated?
Your answer
Are you looking for:
Do you own a business?
What financial/property issues are you hoping to deal with in mediation?
Some of our other services may be helpful to you as well.
Our Communication and Conflict Management (CCM) one-day workshops train people in skills that make relationships of all types work more effectively and enjoyably. Our annual 34-hour Community Mediator Training workshop teaches mediation of conflicts and helps promote a more peaceful community. Would you like us to notify you when these are next offered?
Please check the boxes of the trainings in which you are interested:
If you checked one of the boxes above to be notified of trainings, please enter your email address:
Your answer
We also offer custom trainings and group facilitations.
If you would like to discuss the possibility of custom trainings and/or facilitations, please either call us at 707-445-2505 between 10 a.m. and 2 p.m. Mondays through Thursdays. If you would like us to reach out to you, please enter your phone number below:
If you would like us to get in touch with you to discuss possible custom trainings or facilitations, please enter your phone number:
Your answer
As soon as we receive this completed intake questionnaire, your completed fee schedule and your fees, we can assign mediators to your case.
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