Family Mediation Intake Form
Cleveland Mediation Center Intake Form
Sign in to Google to save your progress. Learn more
Email *
I am interested in the mediation at Cleveland Mediation Center. Please contact me for an intake appointment.
Name *
 Phone number *
Address *
Please tell us who referred you to our program? *
Briefly describe your situation *
Gender
Date of Birth: *
MM
/
DD
/
YYYY
Race: *
Are you hispanic? *
Annual Household Income *
Number of people in household: *
Street Address: *
City & State: *
Zip Code: *
Phone Number: *
Email Address:
Best days for you to meet:
Best time of day to meet:
Name of other party: *
CMC charges $225 per 90 minute mediation session, to be split between the parties. Some parties may qualify for sliding scale pricing. If parties would like a written Memorandum of Understanding completed by the mediator, there will be an additional charge of $125.
Please Note:

1. This form must be submitted by both parties and received by CMC before appointments are scheduled.
2. We will only re-schedule a mediation session twice before cancelling.
3. Fees are collected at or before the start of each session.
Please read the statements below. *
Required
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy