CLIENT CONTACT INFORMATION

Zip Code:

Select an option 92943 93426 93450 93901 93902 93905 93906 93907 93908 93912 93915 93920 93921 93922 93923 93924 93925 93926 93927 93928 93930 93932 93933 93940 93942 93943 93944 93950 93953 93954 93955 93960 93962 95001 95003 95004 95005 95006 95007 95010 95012 95017 95018 95019 95023 95024 95033 95039 95041 95043 95045 95060 95061 95062 95063 95064 95065 95066 95067 95073 95075 95076 95077

City:

Select an option Aptos Aromas Ben Lomond Big Sur Bonny Doon Boulder Creek Bradley Brookdale Capitola Carmel Carmel Valley Castroville Chualar Corral De Tierra Corralitos Davenport Del Rey Oaks Felton Fort Hunter Liggett Freedom Gonzales Greenfield Hollister King City Lockwood Los Gatos Marina Monterey Moss Landing Mount Hermon Pacific Grove Paicines Pebble Beach Presidio Of Monterey Prunedale Salinas San Ardo San Juan Bautista San Lucas Sand City Santa Cruz Soledad Soquel Spreckels Tres Pinos Watsonville

Preferred Method of Contact:

Select an option Phone Text Email

Preferred Pronouns:

Select an option She/Her He/Him They/Them She/They He/They Prefer not to say Other

ACCESSIBILITY & ACCOMMODATIONS

Do you require an interpreter?

Yes

Please specify the language:

No

Do you require any accommodations for a disability?

Yes

Please describe:

No

CASE INFORMATION

Primary Issue:

Auto Accident

Auto Sale

Business/Commercial

Contstruction/Contractor

Landlord/Tenant

Domestic/Family

Elder

Employment/Workplace

Home Owners Association

Loan

Neighbor

Personal Injury

Real Estate

Roommate

School/Youth

Other

Please Specify:

Secondary Issue:

Auto Accident

Auto Sale

Business/Commercial

Contstruction/Contractor

Landlord/Tenant

Domestic/Family

Elder

Employment/Workplace

Home Owners Association

Loan

Neighbor

Personal Injury

Real Estate

Roommate

School/Youth

Other

Please Specify:

Do you have an open court case?

Yes

Case Number:

No

Is there a court hearing scheduled?

Yes

Hearing Date:

(MM/DD/YYYY)

No

Are you represented by an attorney?

Select an option Yes No

How did you hear about our mediation services?

Court Referral

Attorney

Community Organization

Legal Clinic

Government Agency

Online

Other

Please Specify:

Have you used our mediation services before?

Select an option Yes No

OTHER PARTY

Other Party 1:

List Details

First Name: Middle Name: Last Name: Phone Number: Relationship to Other Party:

Not Applicable

Other Party 2:

List Details

First Name: Middle Name: Last Name: Phone Number: Relationship to Other Party:

Not Applicable

Other Party 3:

List Details

First Name: Middle Name: Last Name: Phone Number: Relationship to Other Party:

Not Applicable

Other Party 4:

List Details

First Name: Middle Name: Last Name: Phone Number: Relationship to Other Party:

Not Applicable

CONFLICT DETAILS

Brief Description of the Conflict:

Have you spoken with the other party(ies) about this situation?

Select an option Yes No

VOLUNTARY DEMOGRAPHIC INFORMATION

Gender:

Select an option Male Female Non-Binary Decline to Answer

Race/Ethnicity:

Select an option American Indian or Alaska Native Asian Black or African American Latino or Hispanic Middle Eastern or North African Native Hawaiian or Pacific Islander White Other Race, Ethnicity, or Origin Decline to Answer

Age Group:

Select an option Under 18 18-29 30-44 45-64 65+

Do you currently receive any public assistance benefits?

(e.g., Medi-Cal, CalFresh/SNAP, SSI, CalWORKs, or Section 8 housing)

Select an option Yes No

Household Size

Total Number of People (Including Yourself):

Number of Children Under 18:

Which range best describes your total household annual income before taxes?

Select an option Under $35,000 $35,001 to $65,000 $65,001 to $95,000 Over $95,000

THANK YOU