Three or more Mutually Agreed Upon Dates AND Times
*
Each date/time must be at least 5 days out from the date this form is submitted.
Petitioner's Name
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First Name
Last Name
Petitioner's Email Address
*
Petitioner's Phone Number
*
Petitioner's Current Address
Respondent's Name
*
First Name
Last Name
Respondent's Email Address
*
Respondent's Phone Number
*
Respondent's Current Address
Petitioner's Attorney Name, Email, and Phone Number
*
If Petitioner is not represented, state "Not Represented"
Respondent's Attorney Name, Email, and Phone Number
*
If Respondent is not represented, state "Not Represented"
Issues to be Mediated
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Check one or more boxes below.
Number of Minor Children of this Marriage/Relationship
0
1
2
3
4+
Name of Person Submitting This Form
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Acknowledgment - No Legal Advice
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By checking this box, I acknowledge that I understand that Andrea McAlpine is not my attorney, and cannot give me legal advice. She is also not the opposing party's attorney, and cannot give him/her legal advice. I understand that any and all mediated agreements that Andrea McAlpine may help me reach should be reviewed by an independent attorney of my choosing, which I will have responsibility for paying separately according to that attorney's terms.
Acknowledgment - Hourly Rate
*
I understand that Andrea McAlpine is paid by the hour, and if I choose to pay Andrea McAlpine to mediate my case, this does not establish an attorney-client relationship, nor am I paying her for legal advice.