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Request a Mediation

Fill out this form to begin your mediation process.

TIP! To submit this form, you will need:

Current contact information for all parties
Any court orders pertaining to your case
Payment

Do you have an attorney that will attend the mediation?(Required)

Yes

Mediation styles with pricing (per party)(Required)

Mediation $200 per party

Landlord/Tenant – NOT RELATED to Eviction Resolution Program $50

Teen with parent $250

Workplace Facilitative $300 per party

Mediation pricing (per party)

Settlement Conference $250 per party

Case Type:(Required)

*For additional help and information regarding your case type, visit www.WashingtonLawHelp.org

I would like to request a fee adjustment

Yes, I will submit a $50 non-refundable deposit with my application and supporting documents.

I would like to request separate rooms

Yes ($50 applied to each party requesting separate rooms)

Provide specific issue(s) for requesting a mediation(Required)

For Parenting Plans, Dissolutions, or other cases involving OR impacting children, please indicate the number of children:(Required)

Please enter a number from 0 to 12.

Party Initiating mediation request:

Name(Required)

First Last

Address(Required)

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

Contact Number(Required)

Contact Number Type(Required)

Support Person*

What is a support person’s role?

Support people are always welcome in the waiting room.
For a Settlement Conference, at the mediator’s discretion, a support person may participate in the mediation.
For a Facilitative Mediation, by mutual agreement, a support person may be present in the mediation room.

How were you referred to the Center?

Party Responding to mediation request:

Name(Required)

First Last

Address

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

Contact Number

Contact Number Type

Does the responding party have an attorney that will attend the mediation?

Yes

Attorney for Initiating Party

Please fill in the following ONLY if you have an attorney AND they will be attending the mediation. Requesting attorney is responsible for coordinating 3 mutually agreeable dates and times.

Name

First Last

Address

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

Phone:

Fax:

Contact:

Attorney for Responding Party

Name

First Last

Address

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

Phone:

Fax:

Contact:

Teen With Parent Mediation Request

Parent/Guardian

Name

First Last

Cell Phone

Alternate Phone Number

Address

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

Other Parent/Guardian

Name

First Last

Cell Phone

Alternate Phone Number

Address

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

Teenager

Name

First Last

Cell Phone

Alternate Phone Number

Address

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

Additional Person Attending

Name

First Last

Cell Phone

Alternate Phone Number

Address

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

General Workplace Mediation Request

Supervisor or Party requesting mediation

Name

First Last

Title

Work Phone

Alternate Phone Number

Fax

Work Email

Work Address

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

Party to Participate in mediation

Name

First Last

Title

Work Phone

Alternate Phone Number

Fax

Work Email

Work Address

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

Party to Participate in mediation

Name

First Last

Title

Work Phone

Alternate Phone Number

Fax

Work Email

Work Address

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

Party to Participate in mediation

Name

First Last

Title

Work Phone

Alternate Phone Number

Fax

Work Email

Work Address

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

Mediation Details

Do any PROTECTION or RESTRAINING ORDERS exist between the parties?(Required)

YES

File(Required)

Drop files here or

Max. file size: 256 MB.

If yes, copy of current orders are required with this form. Photos of documents MUST be legible.
After you select a file from your computer, the file will upload when you submit this completed form (“Submit Mediation Request Form” at the bottom of this page.) If you do not have a copy of the order, please contact our office at (253) 572-3657.

Would you like a virtual or in-person mediation?(Required)

Virtual

In-person, limited availability until further notice.

For Settlement Conference only:

Does this need to be reported to the Pierce County Superior Court?

Yes

Case #:

Trial Date:

Judge:

Petitioner:

Scheduling

Please list 3 dates and times, which are 5 or more weeks out from the date of your payment.

Monday – Thursday: 9:00 AM, 1:00 PM, 5:30 PM

Friday: 9:00 AM, 1:00 PM

Saturday: 10:00 AM

1.(Required)

2.(Required)

3.(Required)

Fee Adjustment Reduction Application

Additional information required

# of adults living in your house as a family(Required)

# of children living in your house(Required)

Household monthly earnings before taxes(Required)

NOTE: **You must include a copy of ALL HOUSEHOLD MONTHLY EARNINGS FOR THE PAST 3 MONTHS to be considered for a fee adjustment. Household monthly earnings equal the monthly income of ALL adults living in the home as a family, regardless of marital or familial status. Examples of income documentation might be bank statements, pay stubs, SSI award letters, DSHS letters, etc.

Upload your files

Max. file size: 256 MB.

Does your household receive GOVERNMENT assistance?(Required)

Yes

List type:(Required)

Medical, Food, Cash, etc.

List dollar amount per month:(Required)

Does your household receive NON-GOVERNMENT assistance?(Required)

Yes

List type:(Required)

Medical, Food, Cash, etc.

List dollar amount per month:(Required)

Total monthly income (before taxes) including government assistance.(Required)

List TOTAL dollar amount per month

Reason(s) for fee adjustment request:(Required)

List any circumstances you wish the Center to consider

Payment:

Rescheduling and Cancellations

The party who postpones
- A) within 10 business days of the scheduled mediation date will pay a rescheduling fee of $50.00 or
- B) within 2 business days will pay a rescheduling fee of $200.00
Parties must agree on and re-schedule a new mediation within 60 days of the postponement date.
When a session is cancelled within 10 business days of a scheduled mediation by any party, the entire fee for both parties is nonrefundable.
When a case is closed prior to being scheduled or a session is cancelled prior to 10 business days before the scheduled mediation date by any party, CDR retains $100.00 per party for administrative services.

SECOND SESSIONS: When an additional session is requested following a completed mediation, standard mediation rates apply.

Agree to terms(Required)

I agree and understand the rescheduling and cancellation policies.

Total

For a Workplace Mediation, the Organizational Representative is responsible for fees and costs.

Submitting this form means that you are accepting responsibility for all fees associated with the services to be offered by CDR.

Payment method

Secure online payment

Check, cash, or other payment

*To make payment for both parties, select the second option and please contact the Center.

Contact us or remit your payment to:

Center for Dialog & Resolution
717 Tacoma Ave. South
Tacoma, WA 98402

Cases will not be processed until payment is received.

Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number
Expiration Date Month Year
Security Code Cardholder Name

Mediation

Training

Facilitation

Request a Mediation

Fill out this form to begin your mediation process.

Party Initiating mediation request:

Party Responding to mediation request:

Attorney for Initiating Party

Attorney for Responding Party

Teen With Parent Mediation Request

General Workplace Mediation Request

Mediation Details

For Settlement Conference only:

Scheduling

Fee Adjustment Reduction Application

Additional information required

Payment:

For a Workplace Mediation, the Organizational Representative is responsible for fees and costs.