Mediation Services of Maui - request for mediation

Please fill this out with all of your information
and as much information as you have
on the party you would like to mediate with.

Today's Date How did you hear about us? Has the other party agreed to come to mediation? Yes No
Your Information
Your Name:
Address:
City:
State:
Zip Code:
Phone:
Phone2:
Fax:

Who do you want to invite to mediation?
Their Name:
Address:
City:
State:
Zip Code:
Phone:
Phone2:
Fax:
USE THIS SECTION ONLY IF THE COURTS SENT YOU: Which court heard your case: Wailuku Lahaina Court docket # Date ordered to mediation: Judge: Return date: