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Individual Forms

General Mediation

This form does not include all of the information needed to open a parenting plan case. If you need to mediate issues related to parenting from two homes, please complete this form instead.

This form does not allow for application for reduced fees. If you need to mediate issues not related to parenting from two homes but intend to apply for reduced fees, please complete this form instead.

Please allow 15-20 minutes to fill out this form. Before you get started, make sure you have:

  • Contact information for the other person you would like to mediate with and anyone else you would like us to provide information to;
  • Your debit or credit card to process the fees that allow us to schedule your individual session ($139.00) or the fees required to schedule your individual and regular mediation sessions ($439).
About You
First Name *
Last Name *
First Name
Last Name
Country
Address Line 1 *
City *
State/Province *
Postal Code *
I agree to accept texts at this number:
I regularly check this email:
About the Person You Would Like to Mediate with
First Name *
Last Name *
First Name
Last Name
Country
Address Line 1 *
City *
State/Province *
Postal Code *
About Your Case
Is your case filed in court?
Have you been court ordered to participate in mediation?
Case numbers start with a two-letter code: CI, CR, JV, PR, SC, or TR
Do you currently have an attorney in this matter?
Does the other person currently have an attorney in this matter?
About the Relationship
How long have you known the other person?
Is there a current protection order in place?:
Is there a history of protection orders or police calls between the two of you?
Do you think the other person is expecting to hear from us?
About Mediation

By signing below, you consent to mediate with the other person identified above according to terms of current Mediation West Policy. To read the full policy click here. Highlights of the policy include:

  • Mediation is voluntary and agreements cannot be forced upon you. You have the option to review any agreements with an attorney before signing if you wish.
  • Mediation West keeps the content of your sessions confidential but may need to report process information such as progress and scheduling.
  • You agree to keep the content of the session confidential and agree:
    • Not to record or transcribe sessions.
    • Identify anyone who could potentially overhear a session if joining by phone or video conference.

Recordings/transcriptions of sessions are not admissible in court and allowing other people to listen to sessions is strictly forbidden and may void any agreement reached. 


Mediation West may share information about your case under certain circumstances (to read the full policy click here). If you would like us to release/receive information to/from someone, we need your authorization by checking the corresponding box below:

Release of Information to:
Release of Information to:
Release of Information to:
Release of Information to:

Fees for services are due and payable before sessions can be scheduled and refunds are limited (to read the full policy click here).  When opening your case today, you will need to do one of the following:

  • submit a payment of $139.00 to break your payment into two parts. (This payment will allow us to schedule your individual session. An additional payment of $300.00 will be required before we can schedule your joint/caucus session.) OR
  • submit a $439 payment to take care of your initial fees. (This payment will allow you to schedule your individual session and first joint session. Additional payments will only be required if your mediation requires multiple joint sessions.)

Statistical Information

As a Nebraska ODR-approved mediation center, Mediation West is subject to reporting requirements which includes the following statistical information. Your answers to these questions will assist us in completing these reports.

Gender
Ethnicity

Sign Below

I agree that clicking the "I Accept" button and entering my full name below shall constitute an electronic signature, and along with processing my payment, constitute valid evidence of my consent to mediate under the policies of Mediation West. I understand I am solely responsible for reviewing and understanding all the terms and conditions. I agree the electronically stored copy of this consent is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.

Electronic Signature:
First Name *
Last Name *
Mediation Fee(s)
A partial deposit of $139.00 allows us to schedule your individual session. A second payment of $300.00 will be required prior to scheduling your first regular session. A full deposit of $439 allows us to schedule your individual and first regular session.
Credit Card Information
Visa MasterCard American Express Discover
Cover the fee associated with this online transaction?
Cover the fee associated with this online transaction?
Your total payment will be
Your credit balance will cover
Your credit card will be charged
Your bank account will be charged
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