Form

Mediation Intake & Case Summary Form

Structured interactive intake to capture facts, desired outcomes, safety checks, and triage signals before third-party mediation. Saves submissions for review and helps mediators decide safe next steps.

Interactive Tool

Mediation Intake & Case Summary

Use this intake to capture the facts, outcomes, and safety checks needed to prepare a neutral third-party mediation. If you are unsure about immediate safety risks or legal obligations, pause and contact HR or legal counsel before proceeding. Do not attach sensitive medical records here; follow your organization's secure document process.

YYYY-MM-DD. Defaults to today if left blank.
Your full name or 'Anonymous' if you prefer not to provide a name.
Provide a way for the mediator to reach you. If anonymous, note preferred contact method.
How are you related to the case?
List names, roles, teams, and contact info if available.
Describe working relationships, reporting lines, and any ongoing dependencies between the parties.
Describe what happened, focusing on observable behaviors and events.
List dates and short notes for important events or incidents.
Note any conversations, informal coaching, written warnings, or other actions already taken.
Be specific—examples: restore working relationship, clarify expectations, agree on behavior changes, restitution, process improvements.
Select how you want information to be treated.
Does the submitting party consent to mediation and voluntary participation?
If yes, the mediator should pause and coordinate with safety/HR/legal before any joint session.
Provide any relevant information about threats, disabilities, accommodations, security concerns, or requests for separate sessions.
Examples: active threats, restraining orders, recent violence. If yes, contact emergency services and HR/legal first.
These help triage the case.
If consulted, summarize key guidance in the notes field below.
Capture any mandatory steps, confidentiality restrictions, or legal constraints.
1 = low priority, 5 = immediate priority
1.0 10.0
Optional: named mediator or particular experience needed (e.g., cross-cultural, union expertise).
Days/times participants are generally available. Mediator will confirm scheduling separately.
List documents you will provide (emails, screenshots, policies). Upload instructions: send documents to the organization's secure intake channel. Do not include sensitive medical records here.
From your perspective, what should happen next? (e.g., separate meetings, coaching, joint session, pause for investigation)
For mediator to complete after intake—triage decision, safety plan, need for HR/legal review.
I understand this intake may be shared with mediator(s), coordinator(s), and, when necessary, HR or legal for safety or compliance reasons.
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