Please enable JavaScript in your browser to complete this form. - Step 1 of 2Date / TimeDateTimeName *FirstLastWho is Requesting Mediation *Plaintiff / ClaimantDefendant / RespondentOtherPlaintiff/Claimant is the person who has the disagreement and request resolution. Defendant / Respondent is the person responding to the claimant's request for resolution. Who is requesting mediation *ClaimantClaimant's AttorneyRespondent Respondent's AttorneyJudgeMagistrate CourtA FriendMMC StaffOther AgencyPlease indicate who referred the dispute to mediation. (check all that apply) What type of Mediation are you requesting *CommunityFamily (non divorce / children custody, visitation, support)Landlord-TenantNeighborhood Association (HOA)Employee RelatedBusiness to BusinessBusiness - CustomerContractFaith / Ecumenical OtherPlease indicate the type of dispute you are attempting to resolve. Other type of disputePlease specify the other type of dispute you would like to mediateSafety *YesNoWould you or anyone participating in mediation have a concern about sitting or being present in the same room with the other party in an effort to resolve the matter in dispute? NextName *FirstLastAre you the Claimant or Respondent *Plaintiff / ClaimantDefendant / RespondentPlaintiff/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 *Email *EmailConfirm EmailAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSection DividerName of Company (if not an individual dispute)Business RepresentativeFirstLast (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)PhoneEmail *EmailConfirm EmailAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeSection DividerClaim / 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 situationDetail 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 2 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? *YesNoAre you aware of the expectation of Mediation? *YesNoMediation 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? *YesNoWe 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? *YesNoOther Person/Business Representative *FirstLastBusiness Name (if applicable) Phone *Please provide a phone number by which Midlands Mediation Center can contact the person. Email *Please provide an email address by which Midlands Mediation Center can contact the person. AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeAre you related to the aforementioned person *YesNoRelationship Did the person agree to mediation? *YesNoSubmit