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Family Mediation
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Family Mediation Inquiry Form
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Client Information
Date
(required)
Your First Name
(required)
Your Last Name
(required)
Preferred phone number
May we leave messages on this number?
Yes
No
How did you hear about NVMS?
Other party’s name
Are you married to the other party?
Have you talked with the other party about mediation?
Yes
No
Are they ready to proceed with the mediation process??
Yes
No
Unknown
Please select your range of income for fee assessment purposes (joint income if married, individual if not married to other party)
Over $100,000/year
Over $60,000/year and under $100,000/year
Over $25,000/year and under $60,000/year
Under $25,000/year
What dates and times would you be available for your first session? Please list three. (This will be a two hour session. Please know that scheduling is based on mediator availability, and AT LEAST two business days notice is needed)
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