Mediation Services

Workplace Intake Form

Workplace Mediation - Intake Application

Mediation Services Community Mediation Process: When your completed Intake Application has been submitted, a caseworker will first contact the POINT OF CONTACT as indicated on the application.

If you need help completing this application form, or have further questions, please contact our offices at 1(204)925-3410 and ask to speak with a workplace mediator.

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


    Point of Contact

    Parties in Conflict

    Person 1

    Person 2

    Person 3

    Additional Parties

    Situation Information

    How would you rate the level of emotion for each party?

    Please note: upon successful submission of this form, a confirmation email will be sent to you to acknowledge its receipt. If you do not receive this confirmation email within 2 hours, please check your junk or spam folder. In case you still haven't received it, please don't hesitate to reach out to us directly at

    If you have questions,
    please don’t hesitate to call.


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