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 have 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.)
Please type a phone number or email address. If you enter a phone number, can we text you?
How long has this conflict existed?
A month or less
Less than 6 months
6 months to a year
What other steps have you taken to try to resolve this conflict?
Called the other party
Wrote to the other party
Friends/family have helped me
Hired a lawyer
Went to court
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?
Keep talking to the other party
Ignore the problem
Hire a lawyer
Go to court
During this conflict, has there been violence or threat(s) of violence?
If there has been violence or threat(s) of violence, please describe:
If there has been violence, was it reported?
If violence was reported, to whom was it reported?
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.
What do you hope to achieve through mediation?
What times/days of the week are best for you to meet?
What other information would help us better handle your case?
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