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Individual Forms

Form E

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 includes a reduced fee application, if you need to mediate issues not related to parenting from two homes but do not 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 person you would like to mediate with and anyone else you would like us to provide information to;
  • Income verification that you can upload for each adult you are claiming in your household size; and,
  • Your debit or credit to process your processing fee $39
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 the cell phone number:
I regularly check this email:
About the Other Person You Would Like to Mediate with
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.
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 parent 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 submit a $39 payment, complete the reduced fee application below, and upload the required income verification. Once your application for reduced fees is processed, you will receive a link with the balance due and instructions for submitting your payment.

Application for Reduced Fees

Mediation West offers a sliding fee scale based on your household size and income. You will need to provide income verification for each adult counted in your household size to pass audit requirements.

Income verification must be provided for each adult used to figure household size. Please indicate which item(s) you will be uploading.
Auditors require income verification to apply grant funds to your case.
No file selected
When using paystubs to verify income, a second paystub is required.
No file selected

With my electronic signature, I certify that as of today’s date, my gross household income and the number of people living in my household are as I have indicated above. I understand that this information will be used in determining my eligibility for participation in the reduced fee grant program which utilizes federal and state funds; falsification of claims made on this application may subject the reporting party to federal or state penalties.

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 *
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
$39.00
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