Please enable JavaScript in your browser to complete this form.Name *FirstLastPhone Number *Email *Can we add you to our email list? We send out organizational updates, trainings and other events and resources. *YesNoMailing Address *City *State *Zipcode *Which MN county do you live in? *Select OneAitkin CountyAnoka CountyBecker CountyBeltrami CountyBenton CountyBig Stone CountyBlue Earth CountyBrown CountyCarlton CountyCarver CountyCass CountyChippewa CountyChisago CountyClay CountyClearwater CountyCook CountyCottonwood CountyCrow Wing CountyDakota CountyDodge CountyDouglas CountyFaribault CountyFillmore CountyFreeborn CountyGoodhue CountyGrant CountyHennepin CountyHouston CountyHubbard CountyIsanti CountyItasca CountyJackson CountyKanabec CountyKandiyohi CountyKittson CountyKoochiching CountyLac qui Parle CountyLake CountyLake of the Woods CountyLe Sueur CountyLincoln CountyLyon CountyMcLeod CountyMahnomen CountyMarshall CountyMartin CountyMeeker CountyMille Lacs CountyMorrison CountyMower CountyMurray CountyNicollet CountyNobles CountyNorman CountyOlmsted CountyOtter Tail CountyPennington CountyPine CountyPipestone CountyPolk CountyPope CountyRamsey CountyRed Lake CountyRedwood CountyRenville CountyRice CountyRock CountyRoseau CountySaint Louis CountyScott CountySherburne CountySibley CountyStearns CountySteele CountyStevens CountySwift CountyTodd CountyTraverse CountyWabasha CountyWadena CountyWaseca CountyWashington CountyWatonwan CountyWilkin CountyWinona CountyWright CountyYellow Medicine CountyGender *Select OneWomanManTransgender WomanTransgender ManNon-binaryWish To Not RespondWhich age group do you belong to? *Select OneUnder 13 years old13-17 years old18-24 years old25-59 years old60 and overWish To Not RespondWhat is your race/ethnicity? *Select OneAmerican Indian or Alaska NativeAsianBlack or Arican AmericanLatinxNative Hawaiian or Other Pacific IslanderWhiteMulti-RacialOtherWish to Not RespondWhat is your annual household income? *Select OneUnder $20,000$20,001 to $40,000Above $40,000DeclineYou are requesting services for: *Select OneYourselfYour organizationAnother personWhat kind of service are you seeking? *Select OneMediationRestorative ServicesVictim Offender DialoguesHousing HelpWhat type of dispute are you experiencing? *Select oneNeighborsLandlord/tenantFriends/familySchoolEmployer/employeeBusiness/consumerBusiness/businessOtherDescription of the situation: *Name of Second Party *FirstLastPhone Number (Second Party) *Email (Second Party) *If there are additional parties within this dispute, add names/contact information here:For shared parenting mediations, we ask that you list the names and ages of children who are involved. If you are requesting a different type of mediation, please type "N/A". *Do you feel you can say all that you would like to say in front of the other party/parties? *YesNoNot SureWe will be sending information and an invitation to mediate to all parties listed. Do you have any concerns about your personal safety? *YesNoNot SureHas there ever been violence between the parties? *YesNoNot SureVulnerable Adults must have a support person present at their mediation. Are any of the parties classified as a vulnerable adult? *Yes, someone I want to be involved in the mediation is classified as a vulnerable adult.No, no one is classified as a vulnerable adult.Not sureWere you referred by anyone to our organization? *Select OneLaw EnforcementConcillation CourtHousing CourtHarassment CourtJuvenile CourtFamily CourtLocal GovernmentCommunity AgencyMedia/internetFlyer/Printed MaterialWord of MouthOutreach eventAnoka County AttorneySchoolCo-workerOther**If you referred by "Other", please specify:Submit
