MEDIATION IN-TAKE SHEET
FLORIDA COURT RESOLUTION CENTER
STYLE OF CASE: _______________________VS. ________________________
PLAINTIFF/PETITIONER
Name: ___________________________________________________________________________________________________________
Attorney: ___________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________
Telephone ___________________________________________________________________________________________________________
Fax/e-mail ___________________________________________________________________________________________________________
DEFENDANT/RESPONDENT
Name: ___________________________________________________________________________________________________________
Attorney: ___________________________________________________________________________________________________________
Address: ___________________________________________________________________________________________________________
Telephone: ___________________________________________________________________________________________________________
Fax/e-mail ___________________________________________________________________________________________________________
NATURE OF DISPUTE:_________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Preferred Dates (Give at least three (3) dates for mediation)
_______________________________________________________________________
_______________________________________________________________________