Contact

Submit Your Intake Form

Please complete the intake below. Both parties' contact information helps us schedule efficiently. All information is held in strict confidence and reviewed only by your mediator.

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Your Information

First NameLast NameMobile PhoneEmail Address

Other Party's Information

First NameLast NameMobile PhoneEmail Address

Approximate Household Income Approximate Combined Household IncomeUsed only to determine your sliding-scale session rate. All information is held in strict confidence.

About the Matter

Current Parenting Plan (optional)

PDF, DOC, or image. We will review confidentially.

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Major Disputes & Desired ResolutionsBriefly describe the issues at hand and what an ideal outcome would look like for you.

Scheduling Preferences

Desired Timeframe for MediationPreferred Session Format

Preferred Days & Times for SessionsSessions are Monday through Thursday, 10:00 AM to 3:00 PM. Indicate the days and time windows that work best.

How Did You Hear About Us? How Did You Hear About Us?

Practice Information

Hours

Monday through Thursday · 10:00 AM – 3:00 PM
Session Formats

In-person or via Zoom
Email
info@ccmediation.org
Response Time

Within one business day