Initiating Member (Your Name):
Your House Name:
Phone:
Email:
General Availability:

Member You Would Like to Mediate With:
Member's House Name:
Phone:
Email:

Is this request for mediation being filed jointly? Yes   No
Do you take responsibility for causing harm in this conflict? Yes   No

Are you interested in repairing your relationship and/or trust with this person? Yes  No
Please explain:

Based on your understanding, has one of the house rules been broken? Yes   No
Please explain:

Are you concerned that the member you would like to mediate with is exhibiting uncooperative behaviour?
(See definition in Mediation and Member Review Policies)
Yes   No

If yes, do you have evidence of uncooperative behavior, please explain:

Date(s) Conflict Occurred:
Brief Summary of Conflict:

Description of Incident(s):

Summary of why you're requesting mediation and/or anything else you'd like to share:

(Verification you're human): Which of the 50 states do you reside in?