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.
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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 the name of the person with whom you'd like to mediate.  If you are more comfortable typing only the first name and last initial of that person, you will still help us connect your request with the other person's request.  We will not reach out to this person until you give us your explicit ok.
Please type your email address: *
Please type your phone number: *
Please type your mailing address: *
How long has this conflict existed?
Clear selection
What other steps have you taken to try to resolve this conflict?
Is mediation an alternative to court for you?
Clear selection
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?  
Clear selection
If there has been violence or threat(s) of violence, please describe:
If there has been violence, was it reported?
Clear selection
If violence was reported, to whom was it reported?
Is there a restraining order between you?  
If there is a restraining order, we'll need a copy of the restraining order so we can assess if mediation is allowed.  
Clear selection
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 venue(s) for mediation would work for you?  Please check all the "Yes" and "If need be" responses that could be OK for you.  Having more options will likely free up the process of scheduling mediation meetings.
If need be
In person - outside
In person - inside
Zoom videoconference
Clear selection
What times/days of the week are best for you to meet?
What other information would help us better handle your case?
Clear form
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