Intake Form

RJ/Crim/Crim Coco

Thank you for requesting mediation or conflict coaching for your criminal court matter. Please provide as much information as you can so we can best handle your matter.

* Required

Name*

Required

Email

Phone*

Required

Address

Other Party Name

Other Party Email

Other Party Address

Please describe the issue and the charges:*

Required

How did you hear about us?

County

Relationship

Is this case filed in any court? If yes, please select:

Adjournment Date

Docket Number

Date of Birth

Race

Household Income

Defense Counsel Name and Phone Number

Is there an Order of Protection?

Yes

No

Age of the other party:

If applicable, ADA Name and Phone Number

Are there any accommodations that you need or would like us to know about?

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