Please enable JavaScript in your browser to complete this form.Requestor's Name *FirstLastRequestor's Phone Number *Requestor's Email *Are you theClaimant/PlaintiffClaimant Attorney / ParalegalRespondent / DefendantRespondent Attorney / ParalegalOtherWe need to know the role of the person requesting the mediation. The claimant is the person who is contesting a family matter, also known as the plaintiff. The respondent is the person responding to the claimant, also known as the defendant. Each person can be represented by an attorney and the attorney sometimes initiates the scheduling of the mediation. Docket Number#Referred byHow did you learn of the Midlands Mediation Center's ability to provide mediation services? Claimant / Plaintiff Name *FirstLastClaimant / Plaintiff Phone *Claimant / Plaintiff Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeClaimant / Plaintiff Email *EmailConfirm EmailClaimant Annual Income *<$10,000$10,001 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $59,999$60,000 - $69,999>$70,000Estimated gross annual incomeDoes the Claimant / Plaintiff have an attorney? *YesNoClaimant / Plaintiff's Attorney NameFirstLastClaimant / Plaintiff's Attorney EmailClaimant / Plaintiff's Attorney PhoneRespondent / Defendant Name *FirstLastRespondent / Defendant Phone *Respondent / Defendant Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeRespondent / Defendant Email *EmailConfirm EmailRespondent Annual Income *<$10,000$10,001 - $19,999$20,000 - $29,999$30,000 - $39,999$40,000 - $49,999$50,000 - $59,999$60,000 - $69,999>$70,000Estimated gross annual incomeDoes the Respondent / Defendant have an attorney? *YesNoRespondent / Defendant's Attorney NameFirstLastRespondent / Defendant's Attorney Email Respondent / Defendant's Attorney PhoneChild / Children Name and agesGuardian Ad Litem Appointed?YesNoGuardian ad Litem (GAL) NameFirstLastGuardian Ad Litem's EmailGuardian Ad Litem's PhoneDo you have a GAL's Report?YesNoContested Issues *Parental CustodyChild VisitationAlimony/SupportNon-Parental Custody (grandparent/other)PaternityMilitary IssuesChild SupportProperty and Debt DivisionAttorney FeesAny history of domestic violence *YesNoIs there a need for a translator?YesNo365 Filing DeadlineOther / CommentsPlease share any additional information the mediator will need to assist with your mediation. DropdownFirst ChoiceSecond ChoiceThird ChoicePhoneSubmit
