Individual form mediation

UNITY LEGAL SOLUTIONS MEDIATION ENQUIRY FORM

Please complete this Form so that Unity Legal Solutions (“ULS”) can evaluate your Mediation needs and make proposals as to whether or not ULS can meet those needs.
By completing this form, you do not agree to any Mediation and you do not retain ULS, or any member(s) of its Mediation panel (“Mediators”), for any purposes whatsoever.
ULS and Mediators decline, absolutely, all offers of appointment in connection with any Mediation, or other matter, until such time as ULS and/or a Mediator expressly enters a written Mediation Agreement which, unless otherwise expressly agreed, will be in the un-amended form from time-to-time set out in the relevant section of the ULS Web site, or as otherwise provided by ULS.
When completed, in whole or part, this form will be strictly confidential between you and ULS except that ULS may disclose this form to one or more Mediators in the course of assessing the matters referred to in this form and deciding whether ULS is willing and able to conduct a Mediation in connection therewith.
In this Form, the term “Disagreement” refers solely to the disagreement in so far as it is described below.

* Indicates required field

Date *

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Telephone *

May we contact you directly? *

YES NO

If no, how should we contact you? *

Are you directly involved in the disagreement? *

YES NO

If you ARE directly involved in the Disagreement, please explain how and to what extent: *

If you are NOT directly involved in the Disagreement, please explain why you are completing this Form: *

Who else is involved in the disagreement? Please explain how and why they are involved and where they are located. *

Please describe/explain the Disagreement: *

Who else is involved in the Disagreement? Please explain how and why they are involved and where they are located. *

Have lawyers or other advisors been instructed in connection with the Disagreement? If so and if possible, please identify them and state who they represent. *

Are any court, tribunal or other formal proceedings active in connection with the disagreement? *

YES NO

If YES, please give details. *

When this Form is submitted to ULS, you confirm that, to the best of your knowledge and belief and after making reasonable enquiries, the contents of this Form are true, accurate and correct.

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