Request for Mediation Mediation Request Form Name* First Last Address Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Enter Email Confirm Email Is this case currently in court?* Yes No If yes, which court? Docket/Family File # (if not applicable, write n/a) Where do you live?* Orange County Ulster County Putnam County Sullivan County Somewhere else Name of the Other Party* First Last Phone Number of the Other Party*Email of the Other Party What is your relationship to the other party in the conflict?* Describe the conflict that you are interested in mediating:How did you hear about us?* Court Attorney Family Member / Friend Google search Website CAPTCHA
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