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Center of Restorative Family Mediation
$75/hr Affordable Mediation
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Contact Us

Mediation Intake Form

Please fill out the following form
in order to participate in your mediation session.

First name

Last name

Email

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Who referred you to mediation?

Area of greatest concern for mediation?

Do you have an attorney?

No

Yes

Who are you seeking mediation with?

Are you suffering from a medical condition, illness, or injury?

No

Yes

If you answered yes to any question, please elaborate

Initials

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Mediation Intake Form

Please fill out the following form
in order to participate in your mediation session.

First name

Last name

Email

Date of Birth

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Who referred you to mediation?

Area of greatest concern for mediation?

What happens when you fight? Can you explain what occurs?

Is there an Order for Protection or a restraining order?

No

Yes

Have you had or are you now in counseling?

No

Yes

If yes, with whom?

How Long have you counseling?

A treatment program?

No

Yes

If yes, what type?

Successful completion?

No

Yes

Date Completed

For Divorce or Post Decree Issues Only:

Date of Marriage

Date of Seperation/Divorce

Is there a court file number?

No

Yes

Names and Ages of Children

With whom are the children living with?

Do you have an attorney?

No

Yes

If yes, who?

I declare that the info I’ve provided is accurate & complete

I understand each session costs $25/parent or 1 parent covers the $50 total for a 2 hr mediation session.

I agree to pay 72 hrs in advance or the sesion is subject to cancellation.

Initials

Your Signature

Please Read Terms of the Agreement to Mediate

I accept terms & conditionsAgreement to Mediate

Your Signature for the Agreement to Mediate

Todays Date

525 Main Street #120956 St. Paul, MN 55112
Call or Text: 612-205-2573

Email: thekatallassogroup@gmail.com

Restorative Services Referral

Truancy/Absenteeism Referral

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