Start a Mediation Case – For Individuals

Step 2

**Required field

** Name:	This field is required.
** Address:	This field is required.
Address 2:
** City:	This field is required.
** State:	This field is required.
** Zip:	This field is required.Minimum number of characters not met.
** Phone (please enter at least one):
Home:
Work:
Cell:
** E-mail address:	This field is required.Invalid format.
** Sex:	Please select an item.
** Language Needs:	Please select an item. If yes, please specify:
Special Needs (wheelchair access, etc.):
** Age:	Please select an item.
** Ethnicity:	Caucasian Latina/Latino Asian Native American Pacific Islander Multi-racial OtherPlease make a selection.
How did you hear about SEEDS?
Other Party's Information
** Name:	This field is required.
** Address:	This field is required.
Address 2:
** City:	This field is required.
** State:	This field is required.
** Zip:	This field is required.Minimum number of characters not met.
** Phone (please enter at least one):
Home:
Work:
Cell:
** E-mail address:	This field is required.Invalid format.
** Sex:	Please select an item.
** Language Needs:	Please select an item. If yes, please specify:
Special Needs (wheelchair access, etc.):
Additional Parties:
Legal Information:
** Police involved?	Please select an item.
Officer Name:
Future Court Date:
Referring Judge:
** Brief Summary of the Dispute: This field is required.