Case intake Form

Thank you for your interest in mediation. To start a case with us, please fill out the form below. We’ll send out a welcome packet to both parties that contains a consent form and an application for reduced fees. Once we receive the documents from both parties, we’ll reach out to schedule an Initial Private Session (IPS) with each of you. If you have any questions, feel free to call our office at the number below.

Your Name

Your Email Address

Your Address

Your Phone Number

Your Attorney

Other Person's Name

Other Person's Email

Other Person's Address

Other Party's Phone Number

Other Person's Attorney

*Divorce/Custody/Parenting Plan Only* Children's Names and Ages, separated by a comma.

Court Ordered? Court Ordered? Yes No

Have you mediated with us before? Have you mediated with us before? Yes No

How did you hear about The Mediation Center?

Briefly, tell us what brings you to mediation?

11 + 13 =

The Mediation Center

A 503(c) nonprofit dedicated to providing mediation and conflict resolution services to Lancaster county, Nebraska.

(402) 441-5740

610 J Street, Suite 100

Lincoln, Nebraska 68508

info@themediationcenter.org