Intake Form

Renter / Property Manager or Owner - Request a Mediation

If you are in a housing conflict and interested in mediation services, call us at 612-445-7973 or use this Request a Mediation online form.

* Required

Your Name*

Required

Your Company Name (If Applicable)

Your Email

Your Phone

By checking this box, you agree to receive SMS messages from Conflict Resolution Center. Reply STOP to opt out at any time. Reply HELP for customer care contact information. Message and data rates may apply. Message frequency may vary*

Yes I agree to receive text messages from CRC

No do NOT sent me text messages

Required

Your Address

What County in Minnesota do you live in? (Choose "Outside of Minnesota" if you do not live in Minnesota)

Which CRC Center is closest to your location?

How did you hear about us?

Another Person's Name

Another Person's Company (If Applicable)

Another Person's Email

Another Person's Phone

Another Person's Address

Relationship of Participants

Are you planning to participate or are you referring others?

Yes, I plan to participate

No, I am referring others

How may we help you?

Has an unlawful detainer/eviction action been filed?

Is there a date you need to complete mediation by such as an upcoming court date?

Court Case Number (If Applicable)

Your Gender

Your Race/Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Latinx

Native Hawaiian or Other Pacific Islander

White

Multi-Racial

Other

decline to report

Your Age

Your Household Size

Your Primary Employment Status

Your Approximate Annual Household Income

Your Pronouns (check all that apply)

She/Her

He/Him

They/Them

Other (mark other preferred pronouns in notes section)

Relationship

Advocate

Attorney

Housing Management

Landlord

Referral Source

Social Worker

Support Person

Tenant

Other

My household income meets the program’s limit of 80% of area median income.

Check if "Yes"

My Household has had a decrease in income, increase in expenses , someone has received unemployment payments, or experienced other financial hardsh

Check if "Yes"

Someone in my household is at risk for housing instability or homelessness.

Check if "Yes"

Eligible for HSS funding? (yes if answered YES to the 3 questions above)

Yes

No

Role

Other Party Role

Additional Referral Information: for example if it is 211 you can put "211" here.

Notes: Please do not include any URLs in the form. You might have to click "submit" twice.

By providing a telephone number and submitting the form you are consenting to be contacted by CRC via SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging. No mobile information will be shared with third parties/affiliates for marketing/promotional purposes. All other categories exclude text messaging originator opt-in data and consent; this information will not be shared with any third parties.