“
Community Mediation
”
Community Mediation Inquiry Form
Home
20th Ann. Special Events
About Us
Our People
Annual Reports
Practitioner Awards
Mediation
Family Mediation
Civil Court Mediation
Commercial and Workplace Mediation
Community Mediation
Training
Workshops
Special Events
NVMS Certificate Programs and Intensive Institutes
VA Supreme Court Certification
On-site Trainings
NVMS Trainers
MCLE and CME Credits
Rent Our Training Center
Monday Night Forum
Facilitation
Northern Virginia Mediation Service Facilitators
Group & Meeting Facilitation Inquiry Form
Restorative Justice
R.J. Inquiry Form
News & Events
In the News
Upcoming Events
How Can I Help?
Volunteer Opportunities
Donations
Employment
Job Openings
Internships
Contact Us
Client Information
Date
(required)
Your First Name
(required)
Your Last Name
(required)
Mailing Address
(required)
Email Address
(valid email required)
Cell Phone Number
Work Phone Number
Preferred Contact Number
(required)
Are you directly involved in the dispute/conflict situation?
Yes
No
Case Information
Please explain briefly what issue(s) you would like to address during a facilitated discussion
(required)
Do you have any apprehension regarding emotional and/or physical intimidation from the other party(s)?
Yes
No
If yes, please explain:
Other party(s) names(s) and daytime contact information:
First Name Last Name PhoneNumber E-mail Address
What is your relationship to the other party(s)?
Is mediation required by a contract related to this case?
Are the issues to be addressed in mediation part of a current court case?
Yes
No
If yes, please provide the following:
--------------------------------------------
Court
Type of hearing
Hearing date (mm/dd/yyyy)
Case number
--------------------------------------------
Additional Comments/Questions
delicious