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.

* Required

Your Name*

Required

Your Company Name (If relevant)

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

Required

Your Phone*

Required

Texting Consent

By checking this box, I consent to receive text messages related to CRC services from Conflict Resolution Center. You can reply “STOP” at any time to opt-out. Message and data rates apply. Message frequency may vary, text HELP for assistance. For more information, please visit our privacy policy and SMS terms and conditions

What is your address?*

Required

What county in Minnesota do you live in? (choose "Outside of Minnesota" if you do not live in Minnesota)

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

Required

Another Participant's Name

Another Participant's Company Name (If relevant)

Another Participant's Email

Another Participant's Phone

What is the other participant's address?

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

Required

What is the relationship between the participants?*

Required

Is there an upcoming court date related to this issue?

Has there ever been a court case number for this matter now or in the past? (Please list it here)

What type of dispute is it regarding?*

Required

How did you find out about CRC and mediation?

If you chose "Other", please share how you heard about us here:

CRC Center

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

She/Her

He/Him

They/Them

My pronouns are not listed

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?

How many people are in your household?

What is your primary employment status?

What is your approximate annual household income?

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

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 612-822-9883 for assistance.

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

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.