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What is RJ?
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¿Por qué usar la mediacion?
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Mediation
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Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Restorative Justice
What is RJ?
Principles and Values
The Circle Process
RJ in the Criminal Justice System
RJ in Communities
RJ in Schools
RJ Services
Circle Facilitation
Restorative Conferencing
RJ Training
Schools
Organization and Businesses
RJ Policy and Practice
Community Compact
Studies and Statistics
Allies and Partners
2022 Bilingual Community Conversion Series
Community Conversations
Community Building Conversations
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
En Español
Proprietario / Inquilino – SP
¿Por qué usar la mediacion?
Involúcrate con la mediación
MMC Noticias
PODCASTS de MMC
Propretario / Inquilino – SP
Servicios de mediación
Search
Close
Donate
About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Restorative Justice
What is RJ?
Principles and Values
The Circle Process
RJ in the Criminal Justice System
RJ in Communities
RJ in Schools
RJ Services
Circle Facilitation
Restorative Conferencing
RJ Training
Schools
Organization and Businesses
RJ Policy and Practice
Community Compact
Studies and Statistics
Allies and Partners
2022 Bilingual Community Conversion Series
Community Conversations
Community Building Conversations
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
En Español
Proprietario / Inquilino – SP
¿Por qué usar la mediacion?
Involúcrate con la mediación
MMC Noticias
PODCASTS de MMC
Propretario / Inquilino – SP
Servicios de mediación
Menu
About Us
Services
Mediation
Restorative Conferencing
Conflict Coaching
Facilitation
Training
Make a Payment
Programs
Landlord & Tenant
Community Conversations
Leadership
Staff/Board
Our Team
Privacy Policy
Resources
Mediation
About Mediation
Why Mediate?
Divorce/ Family Mediation
Domestic Mediation Quesitonnaire
Community Mediation
General Community Mediation Questionnaire
Court Mediation
Getting Started
Apply for Free/Reduced Fees
Make a Payment
Restorative Justice
What is RJ?
Principles and Values
The Circle Process
RJ in the Criminal Justice System
RJ in Communities
RJ in Schools
RJ Services
Circle Facilitation
Restorative Conferencing
RJ Training
Schools
Organization and Businesses
RJ Policy and Practice
Community Compact
Studies and Statistics
Allies and Partners
2022 Bilingual Community Conversion Series
Community Conversations
Community Building Conversations
Landlord & Tenant
Informational Videos
Getting Started
Resources
Community Conversations
Get Involved
Volunteer
Donate Financially
En Español
Proprietario / Inquilino – SP
¿Por qué usar la mediacion?
Involúcrate con la mediación
MMC Noticias
PODCASTS de MMC
Propretario / Inquilino – SP
Servicios de mediación
Search
Close
Donate
Domestic Mediation Questionnaire
Mountain Mediation Center – Domestic Mediation Questionnaire
Please fill out your general information below
Domestic Mediation Questionnaire
Name
Name
First
First
Last
Last
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Cell Phone
Email
Domestic Mediation Questionnaire
What are the main issues you wish to discuss in mediation?
Relationship:
Married
Never Married
New Option
Date of Marriage:
Case Type:
Divorce
Parentage
Modification
Other
Other
Do you have any children?
*
Yes
No
Other
Other
Name(s) and Date(s) of Birth of your child(ren)?
Has this matter been filed in court?
Yes
No
Other
Other
Matter Was Filed in Court
Where was it filed?
What is the case number?
Who was the petitioner?
Who was the respondent?
Who was the judge/commissioner?
Who was your attorney?
What is your attorney's phone number?
Will your attorney be present in the mediation?
Yes
No
Maybe
Other
Other
Protective Order Information
Is there currently a Protective Order in place?
Yes
No
Other
Other
Does this Protective Order prohibit you from meeting with the other party in mediation?
Yes
No
Other
Other
Would you have concerns for your safety if you met with the other party in mediation?
Yes
No
Other
Other
Contact Information for Other Party
Name:
Address
Address
Address
Address
City
City
State/Province
State/Province
Zip/Postal
Zip/Postal
Country
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Côte d'Ivoire
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Cell phone number:
Other phone number:
Email:
Additional Information
Additional information or comments:
If you are human, leave this field blank.
Submit
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