Intake Form Step 1 of 2 50% CONFIDENTIAL MEDIATION INTAKEYOUR PERSONAL INFORMATION IS COMPLETELY CONFIDENTIAL AND WILL NOT BE RELEASED TO ANY OUTSIDE AGENCIES OR OTHER PARTIES. DEMOGRAPHIC DATA IS USED FOR STATISTICAL PURPOSES ONLY.CASE TYPE:*Select One:Auto AccidentBusinessCivil RightsCondominiumConsumer / MerchantDomesticEducation / Special Ed.FamilyForeclosureFriendHomeowners AssociationJob RelatedJuvenileLandlord / TenantNeighborPetReal EstateTROOtherREFERRAL SOURCE:*Select One:Circuit CourtDistrict CourtFamily CourtAOAO / HOAAttorneyBBBCommunity Organization / Social Service AgencyDOEFamily/FriendHawai‘i Civil Rights Committee (HCRC)PoliceProsecutorPublic DefenderRICOSelfOtherPlease specify:* IS THIS CASE PENDING IN COURT?* Yes No COURT CASE NUMBER:* NEXT COURT DATE:* MM slash DD slash YYYY IS THERE A TRO RELATED TO THIS CASE?* Yes No THE TRO IS FROM:* District Court Family Court YOUR INFORMATIONFULL NAME* First Last MAILING ADDRESS* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands CELL PHONE*HOME PHONEWORK PHONEEMAIL* THE BEST WAY TO REACH ME IS BY:*Select One:EmailCellTextHome PhoneWork PhoneATTORNEY/CASE WORKER: FIRM: PHONEI REQUEST LANGUAGE INTERPRETATION SERVICES:* Yes No MY FIRST LANGUAGE IS:* I REQUEST SPECIAL ACCOMMODATIONS:* Yes No I NEED:* ETHNIC BACKGROUND*Please select one that you MOST identify with.Select One:American Indian/Native AmericanAfrican AmericanChineseFilipinoHawaiianHispanic / LatinoJapaneseKoreanSamoanTonganOther AsianOther Pacific IslanderWhite / CaucasianGENDER*Select One:FemaleMaleOtherDATE OF BIRTH:* MM slash DD slash YYYY AGE*ANNUAL HOUSEHOLD INCOME (before taxes, total of all family members living in the house)*Please include: all earnings, unemployment, workers comp, social security, SSI disability, public assistance, veteran benefits, survivor benefits, pension or retirement, alimony, child support, etc. (Do not include food stamps or housing subsidies)Select One:$0 - $10,000$10,001 - $20,000$20,001 - $42,000$42,001 - $62,000$62,001 - $82,000$82,001 - $100,000$100,001 - $150,000$150,001 - $250,000$250,001 – $350,000Over $350,000NUMBER OF FAMILY MEMBERS IN YOUR HOUSEHOLD (including YOU) :*EMPLOYMENT STATUS*Select One:EmployedSelf-EmployedPart-TimeUnemployedRetiredStudentHomemakerMilitaryDisabledTemp. DisabledRELATIONSHIP STATUS*Select One:SinglePartneredMarriedSeparatedDivorcedWidowed MORE DETAILSBRIEFLY DESCRIBE THE PROBLEM YOU HAVE WITH THE OTHER PARTY/PARTIES (be specific):*WHAT OUTCOME WOULD YOU LIKE TO SEE AS THE RESULT OF MEDIATION?*I AM GENERALLY AVAILABLE ON (please mark as many as apply):* Any Day / Time Weekday Mornings Weekday Afternoons Weekday Evenings Saturday Mornings Saturday Afternoons THE PARTY/PARTIES WITH WHOM YOU ARE IN DISPUTE (please provide as much info as you have):FULL NAME* First Last RELATIONSHIP TO YOU* MAILING ADDRESS Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands CELL PHONEOTHER PHONEEMAIL ETHNIC BACKGROUNDSelect One:Select One:American Indian/Native AmericanAfrican AmericanChineseFilipinoHawaiianHispanic / LatinoJapaneseKoreanSamoanTonganOther AsianOther Pacific IslanderWhite / CaucasianGENDERSelect One:FemaleMaleOtherAGEARE THERE CHILDREN DIRECTLY AFFECTED BY THIS SITUATION? (for Family, Divorce, Separation, etc. cases)* Yes No CHILDREN DIRECTLY AFFECTED BY THIS SITUATION (for Family, Divorce, Separation, etc. cases):FULL NAME OF CHILD #1 First Last Relationship of Child #1 To You Age of Child #1Gender of Child #1Select One:FemaleMaleOtherFULL NAME OF CHILD #2 First Last Relationship of Child #2 To You Age of Child #2Gender of Child #2Select One:FemaleMaleOtherFULL NAME OF CHILD #3 First Last Relationship of Child #3 To You Age of Child #3Gender of Child #3Select One:FemaleMaleOtherFULL NAME OF CHILD #4 First Last Relationship of Child #4 To You Age of Child #4Gender of Child #4Select One:FemaleMaleOther Δ
