Civil Mediation Intake - Midlands Mediation Center

Name *

First

Last

Person or representative making the claim / has a disagreement with others

Are you the Claimant or Respondent *

Plaintiff/Claimant is the person who has the disagreement and request resolution. Defendant / Respondent is the person responding to the claimant’s request for resolution.

Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Section Divider

Name of Company (if not an individual dispute)

If the dispute is not an individual but a business dispute

Business Representative

First

Last

(as a corporation or business your representative must have full authority to settle without further consultation (SC ADR Rule 16.08 (A.2)) Both the corporation or Business representative and any attorney or record must appear at mediation. (SC ADR Rule 16.08)

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Section Divider

Claim / Docket Number (if applicable)

Has this matter been referred to court or part of an insurance claim? If so, please provide the claim number for insurance claims and the docket number for court.

Summary of Dispute *

Please provide a brief summary of the situation

Detail Steps Taken to Resolve Dispute *

Please provide detail steps taken of any action to resolve, investigate or otherwise manage the dispute including potential outcomes (please feel free upload the file below)

File Upload

Click or drag files to this area to upload. You can upload up to 4 files.

Please upload additional documents – Preferred MIcrosoft Word, Google Doc or PDF files; if possible save documents as “PDF”.

Special Needs

Please advise us of any specific needs of participants: (translated, accessibility to second-floor facility, lack of internet access (online/virtual services), etc…)

Expectations of Mediation *

Please outline your expectations of the mediation. What do you expect of the outcome in your participation in meditation?

Do you agree to mediate this issue in good faith? *

Are you aware of the expectation of Mediation? *

Mediation is a self-determination process. You and the other person/business are responsible for the outcome. The mediator is neutral and impartial and does not provide any decision related to your outcome. He/she does not advise you on your outcome or any decision you are required to make. You are expected to determine your solution.

Are you aware that mediation can take hours to reach a resolution, are you committed to the two hours allocated for your mediation? *

We have scheduled 2-hours for your mediated session. If you require additional time, the mediator will work with you and the other person/business to schedule additional time. Please note extended time is based on the mediator’s availability as she/he are volunteers of MMC.

Are you available to be reached by phone or email prior to the mediation, if the mediator has questions or needs clarification? *

Other Person/Business Representative

First

Last

Other individuals needed in the decision making process – insurance adjuster, parent/guardian, spouse or other

Business Name (if applicable)

Phone

Please provide a phone number by which Midlands Mediation Center can contact the person.

Please provide an email address by which Midlands Mediation Center can contact the person.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Are you related to the aforementioned person

Did the person agree to mediation?

Checkboxes

First Choice
Second Choice
Third Choice