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Mediation Intake Form

​Mediation provides a supportive place where people can talk through their conflict in a productive manner. A mediator helps people in conflict communicate for better understanding, identify the issues, and each party’s interests, develop creative solutions, negotiate a lasting agreement that works for everyone.

Please fill out all possible information on this form. A Coordinator will reach out to you via phone or email afterward.​

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Your first Payment will occur on

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Please select the total number of Payments you would like to make:

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Your first Payment will occur on .

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Select a Start Date for your Payment(s).

(Your Payment(s) will end after payments.)

Payment will occur on

(Your Payment(s) will be Ongoing and can be cancelled anytime.)
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