Mediation Request Form

Your Name*

Email Address*

Phone Number*

Other Party Name*

Summary of Dispute*

Date Dispute Arose*

Preferred Resolution*

Financial Settlement

Apology / Acknowledgement

Policy Change

Other

Supporting Documents

What is this form?

A mediation request form for parties seeking a neutral third-party mediator to resolve disputes outside of court.

Businesses, individuals, and legal teams pursuing mediation as an alternative dispute resolution method.