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.

Organization:
Address of Organization *
Address of Organization
Point of Contact
Name *
Name
If you selected "other" under "Preferred Pronouns", please indicate preference
Work/Daytime *
Work/Daytime
Cell *
Cell
Parties in 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
How would you rate the level of emotion for each party?
(process, intervention, outcome, etc.)