Intake Form

In-Court Civil and Housing

Thank you for reaching out about possible mediation. Please fill out the form below with as much information as possible so we can properly direct your inquiry.

* Required

Name*

Required

Company

Email

Phone*

Required

Address*

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Other Party Name*

Required

Other Party Company

Other Party Email

Other Party Phone

Other Party Address

Briefly describe the problem*

Required

How did you hear about us?*

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County*

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Relationship

Which court is this filed in?*

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Court Return Date

Docket Number*

Required

Date of Birth

Race

Sex

Household Income

If you have previously spoken to a NYPI staff member, please let us know their name here:

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.