Mediation Inquiry Form
This form is to inquire about a possible mediation with Cleveland Mediation Center. Please answer the required boxes and anything else you feel comfortable answering. We may collect this information from you in the future if mediation is used.
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Today's Date *
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DD
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Name *
My Phone Number is... *
My Email is... *
My Address is...
How did you hear about our program? *
I have a dispute with a...
The Issue is... *
Demographics
Cleveland Mediation Center collects demographics for statistical purposes only. Statistics are pulled together as a combination of data so no information is related to specific people. We use this information to help share the work we do with grant funders to keep mediation accessible for all.
Date of Birth:
MM
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DD
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YYYY
My Race:
My Gender:
Are you hispanic?
Clear selection
Annual Household Income:
Number of people in household:
Best days for you to meet:
Best time of day to meet:
Name of other party: *
Contact information for other party
Agreement to reach out:
By clicking "submit," I am asking Cleveland Mediation Center to reach out to me using the information I have provided to discuss an  inquiry I have with about mediation.

Cleveland Mediation will follow up after receiving this form via phone. 
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