Intake Form

Family Case Intake

New Family Intake

Please fill out all relevant information.

* Required

Your name*

Required

Your email address*

Required

Your phone number*

Required

Your address*

Required

Name of the other party*

Required

Other party's email address

Other party's phone number

Other party's address

Describe the issues that you are hoping to resolve.*

Required

Who referred you to mediation at the DRC?*

Required

What is your relationship to the other party?*

Required

In which county do you live? If you do not live in New York State, choose the county where the other party lives.*

Required

Is this case pending in court? If yes, which court?

Docket Number

If this case is pending in court, what is your next appearance date?

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

Child 1 First & Last Name - M/F - DOB (If not applicable, write n/a)*

Required

Child 2 First & Last Name - M/F - DOB

Child 3 First & Last Name - M/F - DOB

Child 4 First & Last Name - M/F - DOB

Has the other party been told that you would be reaching out to DRC for mediation?*

Required

Secondary phone number

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

Required

Is there an open CPS case on any party?*

Required

How did you hear about mediation and DRC?*

Required

Would you like to receive our newsletter?*

Yes

No

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.