Mediation Intake Form

SELECT MEDIATION, LLC
Florida Supreme Court Certified in Appellate, Circuit Civil, Family and County Mediation

Phone: (321) 269-6900 / Fax: (321) 247-4795
OFFICES THROUGHOUT FLORIDA

County

Case No.

Type of Case

Plaintiff(s)/Petitioner(s)

Attorney, if one

Contact Information:

Mailing Address

City

State

Zip Code

Phone

Fax

Email

Defendant(s)/Respondent(s)

Attorney, if one

Contact Information:

Mailing Address

City

State

Zip Code

Phone

Fax

Email

If there are additional parties to this case, please provide their names, address, and phone numbers

Was mediation court ordered?

Will you be providing a mediation summary?

Is there any other pertinent information that we should know before the mediation session?