Mediation Request Form - Tacoma, Wa
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1
2MEDIATION REQUEST FORM
Center for Dialog & Resolution
717 Tacoma Ave So. ⦁ Tacoma, WA 98402
Phone: 253.572.3657 ⦁ Fax: 253.572.3579 ⦁ Email:
Party initiating mediation request:
Party responding to mediation request:
Name:
Name: __________________________________________
_____________________________________________
Address:
Address: ________________________________________
___________________________________________
___________________________________________________
_________________________________________________
Contact Number: ________________________________
Contact Number: ________________________________
Cell
Home
Work
Cell
Home
Work
(Email)________________________________________
Support Person*:_________________________________
Contact Number: ________________________________
Cell
Home
Work
(first name/relationship)
(Email)________________________________________
How were you referred to the Center? _______________
Please fill in the following
if you have an attorney
they will be attending the mediation.
ONLY
AND
Please fill in the following ONLY if you have an attorney
AND they will be attending.
Initiating attorney is responsible for coordinating mutually agreeable dates and times.
_
Attorney
Attorney
Name: _______________________________________
Name: _______________________________________
Address: _____________________________________
Address: _____________________________________
_____________________________________________
_____________________________________________
(W)________________ (Fax) _____________________
(W)________________ (Fax) _____________________
Contact:______________________________________
Contact:_____________________________________
(Email): ______________________________________
(Email): _______________________________________
Do any PROTECTION or RESTRAINING ORDERS exist between the parties?
⧠
⧠
NO
YES (If yes, copy of current orders are required with this form.)
⧠
⧠
FACILITATIVE MEDIATION?
Do you want a
SETTLEMENT CONFERENCE MEDIATION or a
See all types and fees and comparison chart on back
Payment must accompany this form.
Case Type:
⧠
⧠
For Settlement Conference only:
Parenting Plan Modification
Probate
⧠
⧠
Parenting Plan Original
Commercial
Does this need to be reported to the Pierce County Superior
⧠
⧠
Dissolution with children
Real Property
⧠ No
⧠ Yes
Court?
⧠
⧠
Dissolution without children
Personal Injury
⧠
⧠
Bar Complaint
Landlord/Tenant
Cause #: ______________
Trial Date:___________________
⧠
⧠
Property Claim
Neighborhood
Judge: ________________
Petitioner: ___________________
⧠
⧠
Contract
Other: ______________
Number of Children Affected:__________
Please list 3 dates and times, which are 4-6 weeks out from the date of your payment.
Monday - Thursday: 9:00 AM, 1:00 PM, 5:30 PM / Friday: 9:00 AM, 1:00 PM / Saturday: 10 AM
1. _______________________
2. __________________________
3. ________________________
Rev 02/10/2017
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