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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:

Multi-line address
Do you have a Minnesota court file?
Yes
No
Not sure or it's complicated
Do you have an attorney?
Yes
No
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

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

Information about your children (if any)

How many children do you have?

Information about the other party (leave unknown information blank)

Multi-line address
Do they have an attorney?
Yes
No

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

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.

I hereby certify the information provided is accurate and correct.

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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.

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