Page Title

Mediation
Intake Form

A Child Advocacy Company
Bringing Support to Parents
Building Strength to Children

Disclaimer: BS Kids LLC legal research and information has been prepared for educational and informational purposes only. This material is not legal advice or legal
opinions on any specific matters. Transmission of the information is not intended to create and receipt does not constitute a lawyer-client relationship between BS Kids LLC ,
the author of the information and any other legal publisher. Customers of BS Kids should not act upon this information without seeking professional counsel. The opinions
expressed in the material presented to BS Kids clientele is based on information found in legal publications. BS Kids LLC, 78 Canterberry Court, Hudson, NH 03051
781-756-1214.

Name:

Address1:

Address2:

City:

State:

Zip:

Home Phone:

Cell Phone:

E-MAIL:

Name of other Individual (s) Involved in the Conflict:

Dates of availability (generally) for two-hour blocks of time each day of the week:

Monday

Tuesday

Wednesday

Thursday

Friday

BS KIDS ISSUE IDENTIFICATION FORM

This portion of the intake form is being provided to you so that issues that are important to you will not be
overlooked or forgotten. Mediation is your opportunity to talk about issues that concern you. At the start we
will agree to a list of the matters we need to discuss. In that way, we can hold a balance between the issues
and not lose sight to any of them.

On the lines below, please write down the issues you would like to resolve in the mediation session, in order
of priority.

If there is any additional information you would like to include, please do so in the space below.

Additional Information:

Thank you for your interest in BS KIDS Mediation. A BS KIDS Advocate will contact you shortly. If
you need assistance with this form, please e-mail us at info@bskids.net or call 781-756-1214. BS
KIDS is a Nationally Certified Professional in Mediation. Please note: BS KIDS is not *certified* for
Family Mediation Services under the New Hampshire requirements.

BS KIDS MEDIATION INTAKE FORM

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