Intake Form

Civil Case Intake

New Case Civil Intake

Please complete and submit this intake to start a new case for mediation.

* Required

Name*

Required

Email*

Required

Phone*

Required

Secondary phone number

Address*

Required

Has the other party been told that you are contacting the DRC for mediation?*

Required

Other party's name*

Required

Other party's email address.*

Required

Other party's phone number*

Required

Other Party Address*

Required

What is the issue that you are hoping to resolve?*

Required

Case Type

Who referred you to mediation at the DRC?*

Required

Which county do you live in?*

Required

What is your relationship to the other party?*

Required

Is this case pending in any court?

If this case is pending in court, when is your next hearing date?

If the case is pending in court, do you have the file, docket, or index number of you case?

Primary Language*

Required

Date of Birth*

Required

Race*

Required

Sex*

Required

Educational Attainment*

Required

Employment*

Required

Household Income*

Required

Veteran Status

Disability Status

Number of Persons in Household*

Required

Is there an Order of Protection issued against any party by any court?*

Required

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

If you have any questions, please call Jolynn at 845-372-8771 x5001