Mediation Request Form

Mediation Request Form - New

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Information Regarding the Parties

Petitioner/Plaintiff

Salutation

First Name

Last Name

Respondent/Defendant

Salutation

First Name

Last Name

Are there one or more Minor Children Involved in the Case?

YesNo

Attorney Requesting Mediation

Salutation

First Name

Last Name

Address

Street Address

Address continued

City

State

Zip

Phone Number

Fax Number

E-mail Address

The Attorney Requesting the Mediation Represents:

Petitioner/PlaintiffRespondent/DefendantOther

Other Party's Attorney

Salutation

First Name

Last Name

Address

Street Address

Address continued

City

State

Zip

Phone Number

Fax Number

E-mail Address

The Other Attorney Represents:

Petitioner/PlaintiffRespondent/DefendantOther

Is there any other person who should receive notice of the mediation?

YesNo

Contact Information

Salutation

First Name

Last Name

Fax Number

E-mail Address

Is there any additional person who should receive notice of the mediation?

YesNo

Contact Information

Salutation

First Name

Last Name

Fax Number

E-mail Address

Please submit additional party/contact information or any other information regarding the scheduling of the mediation in the comment section below.

This form is to submit a request for mediation on a specific date. The mediation is not confirmed until the parties have received written confirmation from Mark W. Sims, Attorney-Mediator, that the mediation has been scheduled on the requested date.

If the mediation cannot be scheduled with Mark W. Sims for whatever reason, you will be notified as quickly as possible but no later than the next day after submitting the form.

Once the mediation is scheduled, confirmations will be sent out to the parties via the contact information submitted with this form.

If you do not receive any communication from Mark W. Sims by the next business day after requesting a mediation date or completing this form, please contact Mark W. Sims at texaslaw@austinmediation.com.

By submitting this form, you agree to the cancellation policy (which applies to short notice cancellations) specifically outlined at Mr. Sims' website, www.austinmediation.com.

I have read and agree with the statements above.

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Contact Information

	Name of Child	Age
			MaleFemale
			MaleFemale
			MaleFemale
			MaleFemale
			MaleFemale
			MaleFemale
			MaleFemale