Request for Services

Fill out the following form to request services.

All information in this form is confidential.
If mediation is the requested service, this document is not a public record.

Your Information

First Name

Last Name

Organization

Address

City

State

Zip Code

Phone

Attorney Representation Information

If you or your organization is represented by an attorney, please provide the attorney’s name and contact information.

Attorney Name

Address

City

State

Zip Code

Phone

Confidentiality Agreement

I acknowledge and understand the following:

Mediation communications in connection with Government Conflict Resolution Services (GCRS) are confidential, except that parties may share communications with their attorneys. Confidentiality can be waived if all mediation parties and the mediator consent to the disclosure. If there is a pending lawsuit related to the matter being discussed in the GCRS proceeding, mediation communications in the GCRS proceeding are privileged and cannot be presented to the court without the agreement of the parties unless they fall within an exception specified in the Uniform Mediation Act, Ohio Revised Code Chapter 2710. See Rules 16.40 - 16.43 of the Rules of Superintendence for the Courts of Ohio.

Signed By

Date

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