Civil General Matter Questionnaire
Contact us regarding a Civil General Matter:
Give a concise description of the nature of the matter/issue in dispute:
Full Name:
Phone #:
Email Address:
Street Address:
City:
State/ZIP:  
Are you presently employed?
No
Yes
  How Long?
Job Title:
Have you hired an attorney for this matter?
No
Yes
 
Has this matter been filed with any court?
Other parties to this dispute:
Insurance Companies Involved:
   
   
   
   
   
What agreements have you and the other party(s) already reached?
Negotiation History:
First Offer:
First Response:
Second Offer:
Second Response:
Third Offer:
Third Response:
Fourth Offer:
Fourth Response:

Release of information to Consensus Meediation Services, LLC:


I release the above information to Consensus Conflict Management & Mediation Services, LLC
for the purposes of consultation and mediation in this matter should
I retain their services. I understand that this information will be
destroyed by Consensus Conflict Management & Mediation Services, LLC if I do not retain their
services within thirty (30) days of the date of submittal of this
information to them. I further understand that, in the event I do
retain the services of Consensus Conflict Management & Mediation Services, LLC, the
information provided above will be used as work product and in any
case, all information shall be considered private and confidential at
all times. Consensus Conflict Management & Mediation Services, LLC assures me that all
information provided to them by me or my co-party shall be destroyed
upon completion of mediation. I affirm that I am of lawful age and
authority to provide this information and enter this agreement.
I accept these terms.
I decline these terms.