Peer Mediation Intake Form

Name of Party Requesting Mediation: 

Phone:         

Email:           
 

How are you related to the conflict?

 

Individuals Involved in the Conflict :

Name:

Address:

Phone:

Email:
   

Name:

Address:

Phone:

Email:

Type of Conflict:

Brief Description of the Conflict:

How long has this conflict been going on? 

Steps Taken Prior to Contacting PMC:

Immediate Concerns:

Anything that cannot wait until the intake meeting:

Any additional information needed about the individuals involved: