Contact Information First Name Middle Name (optional) Last Name Address City State OregonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Phone Email Demographic Information Date of Birth Pronoun She He They Other Other Pronouns Primary Language Interpreter needed? Yes No Type of Service: Family Law Court Case Number (if known) Are you represented by an attorney? Yes No The Other Person in Your Case First Name Middle Name (optional) Last Name Phone Email Safety Information There is a Family Abuse Prevention Act (FAPA) restraining order between us. Yes No There is a No Contact provision from a criminal action between us, which makes us ineligible for Family Law mediation. Yes No I prefer to meet in a separate room from the other party. Yes No Availability List all days and times you are generally available to attend a mediated session. This information will be used to help schedule a session. Monday a.m. p.m. Tuesday a.m. p.m. Wednesday a.m. p.m. Thursday a.m. p.m. Additional Information Is there anything else you want us to know about you or your case that will help us serve you best? CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit your client information Leave this field blank
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