Intake Form

General Intake/Community

Thank you for contacting us about possible mediation services. Please fill out as much of the information below as possible in order for us to best direct your inquiry.

* Required

Name*

Required

Email

Phone*

Required

Address

Other Party Name

Other Party Email

Other Party Phone

Other Party Address

Briefly describe the problem*

Required

County*

Required

Relationship

Date of Birth

Race

Sex

Household Income

If you are filling this out for someone else, what is your Name/Organization and phone number?

How did you hear about us?*

Required

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?

Note: Please do not include any URLs in form.