Intake Form

Request a Mediation

If you are in a conflict and interested in mediation services, call us at 612-822-9883 or use the Request a Mediation online form.

Your Name

(Required)

Your Company Name (If relevant)

Your Email (type "N/A" if you do not have an Email)

(R)

Your Phone

(R)

Do you plan to participate in the services you are requesting or are you referring others?

No, I am referring others
Yes, I plan to participate

(R)

Another Participant's Name

Another Participant's Company Name (If relevant)

Another Participant's Email (type "I don't have it" if needed

Another Participant's Phone (type "I don't have it" if needed)

What type of dispute is it regarding?

(R)

Please describe the matter(s) you would like to discuss. (What is your conflict? Who is it with? What should we know?)

(R)

What is the relationship between the participants?

(R)

Is there an upcoming court date related to this issue?

mm/dd/yy

How did you find out about CRC and mediation?

(R)

What is your gender? (Demographic information helps us as a non-profit to improve our services.)

What is your Race or Ethnicity?

   American Indian or Alaska Native
   Asian
   Black or African American
   Latinx
   Native Hawaiian or Other Pacific Islander
   White
   Multi-Racial
   Other
   Decline or Not Reported

What is your age?

What county in Minnesota do you live in?

How many people are in your household?

What is your primary employment status?

What is your highest level of education?

What is your approximate annual household income?

What are your preferred pronouns that we may use to refer to you? (check all that apply)

   She/Her
   He/Him
   They/Them
   I prefer pronouns that are not listed

What city do you live in?

Note: Please do not include any URLs in form.

If the form doesn' t submit on the first try and you are redirected back to this form, simply hit save again. Contact mediation@crcminnesota.org or 612-822-89883 for assistance.

Conflict Resolution Center is a 501(c)3 nonprofit organization.