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WARNING:

Bogus phone calls, emails on jury service may lead to fraud.  If you receive a phone call, text, or email notifying you that you’re in big trouble for failing to show up for jury service, be suspicious.  It’s probably a scam.  Visit our Jury Scams webpage for more information.

Mediation Intake Form

Personal Information

Please tell us about yourself:
Do you have any disability that we should be aware of?

Court Case Information

Children

Custody and Visitation Requests

Physical Custody
Legal Custody

Safety Concerns

This is about domestic violence between you and the other parent.  

The court has special rules that apply to cases involving domestic violence.  Please use this form to alert us as to any concerns regarding domestic violence and safety by answering the questions below.

Have you had a restraining order or protective order in the past?
Do you have a restraining order or protective order now?
Do you feel safe mediating with the other parent?
Are you and the other parent residing together?

Past Incidents

Have you experienced any of the following?
Yelling / Name Calling
Verbal threats of violence
Threats involving guns, knives, other weapon
Choking, strangling, smothering
Are you concerned about future domestic violence?
Please check any that apply:
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