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Request for Mediation
Name of Petitioner:  
Name of Respondent:
Case Number:
Assigned to Judge:
I want to participate in mediation. I ask that the Court order this matter to Conciliation Services for mediation of the issues, based on the following:
1. Select One:




2. Select One:
 and need assistance with preparing our legal document(s). OR
 and need assistance negotiating our dispute.
3. The party is aware I am requesting this service:
4. My preferred method of Mediation:

5. Describe the disagreement (if any). Be brief and specific. (This process is not appropriate for enforcement issues, those must be addressed directly through the court.)
 
Petitioner Information:
Address:
City:
State:
Zip:
Phone:
Email:  
Attorney Name:
Attorney Phone:
Respondent Information:
Address:
City:
State:
Zip:
Phone:
Email:  
Attorney Name:
Attorney Phone:
The individual requesting this service is the:
 
NOTICE TO BOTH PARTIES: After this Request is filed, Conciliation Services will mail an “Order to Attend Mediation” to both parties. WARNING: THERE IS A $166 FEE FOR FAILURE TO ATTEND!
 

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