BBB Central California Mediation Service Request Form

ORIGINATOR

Please Fill in YOUR Information Here:

*Name

*Company

*Address

*City, State, ZIP

*Home Phone

*Work Phone

*Cell Phone

*Email

RESPONDENT

Please Fill in the OTHER PARTY's Information Here:

*Name

*Company

*Address

*City, State, ZIP

*Home Phone

*Work Phone

*Cell Phone

*Email

In the space provided below, please give a general description of the problem or dispute. We do not need to know the details of what happened.

We just need to know what the problem or dispute is about. If the other party agrees to use our services, both sides will have an opportunity later to provide evidence and explain their point of view.

BRIEFLY DESCRIBE THE PROBLEM OR DISPUTE. Mediation is a confidential process for ALL parties including the Mediator.

Please respond to the following questions by checking the appropriate box. If you do not know the answer to a question, you may leave it blank.

Have you previously used any of our Mediation Services?

YES NO

Have any Lawsuits or Criminal Charges been filed (by you or the other party) about this matter or a related matter?

YES Lawsuit(s) Filed YES Criminal Charge(s) Filed NO

Do you have a contract with the other party that requires mediation or arbitration?

YES NO

Are you willing to meet with the other party and one of our Mediators if the other party agrees to mediation?

YES NO

AUTHORIZATION TO PROCEED

By submitting this form, I am requesting Mediation Services’ assistance in resolving a problem or dispute between the parties named above.

I understand that Mediation Services provided by BBB® Serving Central California and Inland Empire Counties will contact and invite the other party to use the dispute resolution services, which may include a face-to-face mediation session.

I further understand that the mediation process is voluntary and that it is an opportunity to reach a mutually acceptable agreement.

The role of the Mediator is to remain neutral throughout this process and facilitate the discussion if both parties are acting in a civil manner.

The Mediator will not make any decisions, provide any legal advice, or act as a representative/advocate for either party named above.