Family Mediation Intake Form

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Cleveland Mediation Center Intake Form

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: *

YYYY

Race: *

Are you hispanic? *

Yes

Annual Household Income *

Number of people in household: *

Street Address: *

City & State: *

Zip Code: *

Phone Number: *

Email Address:

Best days for you to meet:

Monday

Tuesday

Wednesday

Thursday

Friday

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. *

I understand that not all cases are appropriate for mediation and CMC is not obligated to mediate any case.

By submitting this form I am verifying that the above information is true and complete.

Required

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