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Defendant

Case Information

Case Classification(Required)

Auto Accident

Neighbor

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Employment

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Year

Make

Model

Complainant Data

Primary Language(Required)

English

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Referred By

Name(Required)

First Middle Last

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Secondary Phone

Complainant Email

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Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Respondent Data

Primary Language(Required)

English

Spanish

Referred By

Name(Required)

First Middle Last

Primary Phone(Required)

Secondary Phone

Respondent Email

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Mediation proceedings are highly confidential and voluntary in nature and are not subject to disclosure in a Court of Law , unless the information can be discovered independently of the Mediation (Sec. 154.073(c) Texas Civil Practice and Remedies Code), so by my signature below: I acknowledge the importance of preserving the confidentiality of the process and I agree not to subpoena or hold responsible: the Mediators, the Staff of the EPDRC, the Staff of the RGCOG or the RGCOG Board of Directors, for the outcome of this case in litigation or for any action which may be taken by any disputing party involved in this case, before, during, or after the mediation.

Complainant Signature(Required)

Date(Required)

Please provide a brief description of your case in the lines below.

Describe Dispute(Required)

Solution Desired(Required)

A $50.00 NON-REFUNDABLE FILING FEE FOR NEIGHBORHGOOD CASES

AND A $300.00 NON-REFUNDABLE FEE PER PARTY FOR FAMILY CASES IS TO BE PAID AT THE TIME OF FILING COMPLAINT

ALL INFORMATION REQUESTED MUST BE PROVIDED IN ORDER TO PROCESS THE INTAKE

UPON RECEIPT OF LETTER IF COMPLAINTANT DOES NOT CALL IN TO CONFIRM WE WILL CONSIDER MEDIATION SESSION IS NO LONGER NEEDED.

Initials(Required)

Mediation Intake Form

Case Information

Complainant Data

Respondent Data

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Contact Information

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Contact Information

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