Section 1: Contact Information

First name

Last name

Preferred Pronouns

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Email

Preferred Contact Method

Phone

Email

Text

Is this request for yourself, on behalf of someone else, or as an attorney or court representative?

Myself

Someone else (Explain Below)

Attorney

Court Referral

If submitting this form on behalf of someone else, please explain below.

Section 2: Opposing Party Information

Full Name

If other, please describe.

Do you have contact information for the other party?

Yes (Please Provide Below)

No

Other Party's Phone Number (if known):

Other Party's email (if known):

Is the other party aware you are initiating mediation?

Yes

No

Not sure

Section 3: Type of Mediation Requested

Check All That Apply

Parenting Issues (Custody / Parental Responsibilities)

Parenting Time (Visitation Schedules)

Child Support

Divorce (Including property division or spousal support)

Business Dispute

Agricultural or Farm-Related Conflict

Contested Estates/Probate

Other

If you marked "other", please describe:

Section 4: Legal Status

Has a court case been filed regarding this matter?

Yes

No

Not Sure

If yes, please provide the following (if available): Case Number, County and Circuit Court, Judge(if known)

Are you under a court order to mediate?

Yes

No

Do you currently have legal representation?

Yes

No

If Yes, please list attorney's name and contact info

Is the other party represented by an attorney?

Yes

No

Not Sure

If Yes, please list attorney's name and contact info

Section 5: Issues To Be Mediated

Family/Divorce Cases:

If "Other", please explain:

For Commercial or Agricultural Cases:

If "Other", please explain:

Section 6: Safety & Communication

Are there any safety concerns we should be aware of (e.g., domestic violence, restraining orders)?

Yes

No

If Yes, please explain:

Are there any communication challenges between you and the other party (e.g., high conflict, no contact, language barriers)?

Yes

No

If Yes, please explain:

Preferred Mediation Format:

In-Person (Shelbyville)

In-Person (Champaign)

Virtual via Zoom

Travel-based (we will discuss location and fees)

Section 7: Scheduling Preferences

Times You Are Generally Available

Morning

Afternoon

Evening

Are there any days you are unavailable in the next 30 days?

Yes

No

If yes, please list:

Section 8: Additional Information

Anything else you'd like the mediator to know before scheduling your session?

Submission Acknowledgment

By submitting this form, I understand that:

Illinois Mediation Clinic provides neutral mediation services, not legal representation.
Information shared is kept confidential unless required by law.
Completing this form does not guarantee service until confirmed by the clinic.

Signature

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Client Intake Form

Please complete the form below to begin the mediation process. All information is kept confidential. A mediator will review your submission and follow up with next steps.