Form

Mediation & Intake Form

A structured, saveable intake form to help mediators collect consistent case context, safety flags, confidentiality preferences, desired outcomes, constraints, and recommended next steps — enabling safer triage, clearer preparation, and reliable case records.

Interactive Tool

Mediation & Intake Form

Use this form to capture the essential facts, risks, preferences, and desired outcomes for a mediation case. Complete as much as possible; required fields are marked. Saved responses are stored for follow-up, triage, assignment, and reporting.

Optional: use your organization’s case number or leave blank to auto-assign later.
Enter date as YYYY-MM-DD.
Name of person completing this intake.
Who referred the case (HR, manager, self, other).
List each party, role (employee, manager, student, vendor), and contact info if available.
Person who will coordinate scheduling and communications. Include preferred contact method.
Brief chronological summary of relevant events. Include dates, places, and immediate triggers.
Documents, messages, witnesses, or other evidence parties reference. List existing documentation.
Informal conversations, HR steps, performance actions, previous mediations, or other interventions.
Rate current harm or impact on a scale where 1 = minimal (disagreement only) and 5 = severe (safety risk, threat to employment or wellbeing).
1.0 10.0
Select Yes if anyone is at risk of harm, threats have been made, or immediate separation/protection is needed.
Describe nature of risk, who is at risk, any protective measures taken (no-contact orders, security notified, emergency services involved). Fill only if safety concerns exist.
Record parties’ stated confidentiality expectations. Note organizational policy may override preferences.
Optional free-text clarification.
Record any known conflicts of interest or disclosures by the mediator. If conflict exists, do not proceed without reassignment.
Briefly describe the nature of the potential conflict or relationship.
Summarize what each party hopes to achieve through mediation. Useful for agenda setting.
Note any legal, union, compliance, or scheduling constraints that limit possible remedies or timing.
1 = routine scheduling acceptable; 5 = immediate intervention required. Use in triage decisions.
1.0 10.0
Examples: proceed to joint mediation, separate shuttle mediation, refer to HR/legal, immediate safety action.
Primary recommendation for case handling.
Name of mediator assigned after triage.
YYYY-MM-DD — date to check progress or schedule mediation.
List file names or documents relevant to the case. (File upload capability may be added; this field records what should be attached.)
Document whether parties consent to audio/video recording of mediation sessions. Follow organizational policy and local law.
Any other observations, recommendations, or contextual details not captured above.
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