Family Law Mediation Intake Form
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Second Judicial Circuit of Florida
Alternative Dispute Resolution Unit
Leon County Courthouse, Room 248
301 South Monroe Street
Tallahassee Fl, 32301-1861
Family Law Mediation Intake Form
To schedule a mediation appointment complete this form and mail it to the above
address or email it to Mediations@leoncountyfl.gov.
Today’s Date
: ___________________________
Case Number:
___________________________
County:
_________________________________
Are you the:
Petitioner
Respondent
Name:
__________________________________________________________
Address:
_______________________________________________________________________________
Telephone:
Email:
____________________________
__________________________________________ _
Annual Gross Income (Before Taxes):
____________________________
Are there children?
Yes
No
Name(s) of child(ren):
___________________________________________________________________
Date(s) of birth:
_________________________________________________________________________
Sex:
____________________________
Yes
No
Do you have an attorney?
Name of attorney:
_________________________________________________
Attorney’s telephone number:
Email:
________________________
_____________________________
Attorney’s Address:
_____________________________________________________________________
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