Intake | Hansen Mediation LLC

Mediation Intake Form-Sliding Scale Fees Program

Hansen Mediation LLC

*Please answer the following questions to help us schedule and prepare for your mediation. Your information is confidential. We will share it with your attorney if you are represented. We do not share this information with others without your consent. If you have additional information that you'd like to share or didn't have room for in answering other questions, there is also a general comment box at the end of this form where you can add additional information and clarification.

Information about you:

First name

Middle name

Last name

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Specific questions or issues you want addressed

Do you have a Minnesota court file?

Yes

No

Not sure or it's complicated

What is the court file number?

Do you have an attorney?

Yes

No

Attorney name

Attorney email

Attorney phone

We want to make sure that you can actively participate in the mediation session. On a scale of 1-10 below (where 1 is not comfortable at all and 10 is very comfortable), how comfortable are you with participating in mediation with your spouse/partner/ex?

Do either of you currently have a restraining order (no contact order) against the other person?

Yes

No

Let me explain

Have either of you ever applied for or had a restraining order (no contact order) against the other person?

Yes

No

Let me explain

Please upload any restraining (no contact) orders that you have available

Are there any questions or concerns that you'd like to share with us? (optional)

Your Income:

Are you paid hourly or on a salary?

Paid hourly

I have a salary

I don't work or don't have income myself

It's complicated or I don't know

What is your hourly wage or annual salary?

Information about your children (if any)

How many children do you have?

What are their ages? (leave blank if no children)

Information about the other party (leave unknown information blank)

First name

Middle name

Last name

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

County

Do they have an attorney?

Yes

No

Attorney name

Attorney email

Attorney phone

Their income:

Are they paid hourly or on a salary?

Paid hourly

They have a salary

They don't work or don't have an income themselves

It's complicated or I don't know

What is their hourly wage or annual salary?

Contact preference:

Is it OK for us to contact you and your spouse or the other parent in this case at the phone numbers and emails provided:

Yes, it's OK to contact both of us at any of the phone numbers, email addresses and mailing addresses provided.

No, it's more complicated than that and I have some questions or concerns which I'll explain in the answer box below.

If you have any concerns about us contacting you or the other person, explain that here:

What is the best way to contact you?

How did you hear about us?

Is there other information that you'd like us to know as we review your application?

Please upload any court documents that you would like to submit related to this mediation

I hereby certify the information provided is accurate and correct.

Signature

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MPORTANT - By submitting this form I am not guaranteed to be accepted into the Sliding Scale Fees Program and there are further steps that may be required to complete the application process.

QUESTIONS - If you have questions about this form or about the Sliding Fee Program, please email us at HansenMediationLLC@gmail.com

I expect to follow up with you within approximately 3-5 days to move forward with your application.