Mediation Intake Form

Mediation Intake Form
The purpose of this mediation intake form is to collect intake information so Ben Stich can best serve you. Each party to the mediation is required to complete this form prior to a first mediation session. All information provided will be held in confidence. However, Ben Stich reserves the right to report suspected harm or crimes, such as suspicion of child or elder abuse or neglect. If such information comes up Ben Stich will contact you to discuss further. The information you provide will not be shared with the other party (or parties) to the mediation. It will only be reviewed by Ben and, if applicable, any co-mediator or intern approved to work with you.