Community Resolution Centre - Intake Application

About this Application

Please complete this application form as thoroughly as possible to help us have a better understanding of your particular situation. This helps us determine if Mediation Services is the best resource for you at this time or if another resource would better fit your needs.

Mediation Services Community Mediation Process

When your completed Intake Application has been received by Mediation Services, a caseworker will contact you. For a better understanding of what the mediation process involves, please explore our website www.mediationserviceswpg.ca and read over the Community Program brochure on the main page. If you need help completing this application form, or have further questions please contact our offices at 204.925.3410 and ask to speak with a Community Intake worker

All personal information provided in this application is used for Mediation Services internal purposes only.

General Info
About You
Name *
Name
If you selected "other" under "Preferred Pronouns", please indicate preference
Address *
Address
Work/Daytime *
Work/Daytime
Cell
Cell
Persons directly involved in this conflict
Person #1
Name
Name
If you selected "other" under "Preferred Pronouns", please indicate preference
Work/Daytime
Work/Daytime
Cell
Cell
Person #2
Name
Name
If you selected "other" under "Preferred Pronouns", please indicate preference
Work/Daytime
Work/Daytime
Cell
Cell
Person #3
Name
Name
If you selected "other" under "Preferred Pronouns", please indicate preference
Work/Daytime
Work/Daytime
Cell
Cell
Additional Parties
Please use this space to include information on other parties that may be involved
Situation Information
Please check the statement that best describes your situation: *
How would you rate the level of emotion for yourself and others?
(process, intervention, outcome, etc.)