Mediation is a confidential process. This online communication is part of a "mediation consultation" and therefore confidential.

I have a conflict and I'd like to speak with a mediator about how The CCR can help me without going to court.

I'm requesting:

Mediation Conciliation Facilitation Consumer-Debt Options Counseling Not Sure - Help Me Decide Please click here for a description of services

Please push tab button to move from question to question.

My Last Name
My First Name
Address Line 1
Address Line 2
City
State
Zip
Phone
Best Time of Day To Call
Email
How did you hear about us?	The CCR Website Other Agency Website Attorney(s) County Bar Association Courts Government/Public Organization or Agency Law Enforcement Agency Poster/Advertisement Presentation/Speaker Private or Non-Profit Organization Prosecutorial Office Schools Self-Referral Small Claims Advisory Private Individual Other Unknown/Decline to State Please specify:
Please describe your conflict:	This information will be shared with the other party or parties, if you give us permission to contact them for service.
Please Put All Confidential Information for the Mediator(s) Here:	This information will not be shared with the other party or parties.
My Suggested Resolution of the Conflict is:
Dispute Type	Business-Business Consumer-Merchant Victim-Offender Family/Domestic Government/Public Agency Landlord-Tenant Neighbor-Neighbor Organizations Personal Injury/Property Damage Students Workplace-related Other
Are you represented by an attorney?	Yes No If yes, Attorney's name:
Are other parties represented by attorneys?	Yes No
Is a court case filed?	Yes No Court Case Number, if known:

Statistical Information

Does anyone involved live or work in Los Angeles County?	Yes No
Have you used the services of The CCR before?	Yes No
I am participating in this dispute as:	an individual an attorney
Participant Description	Please Select
Gender	Female Male Other Decline to State N/A (business, organization, etc)
Age	17 and under 18-39 40-64 65 and over Decline to State N/A (business, organization, etc)
Ethnicity	American Indian/Native Alaskan Asian/Pacific Islander Black - African American Hispanic/Latino White Multiple Ethnicities/Races Other Decline to State N/A (business, organization, etc)
Primary Language	Armenian Cambodian English Farsi Korean Mandarin/Cantonese/Taiwanese Russian Spanish Tagalog Vietnamese Other Decline to State N/A (business, organization, etc) Do you need services in this language? Yes No
Annual Household/Business Income	$20,000 or less $20,001 - $30,000 $30,001 - $50,000 $50,001 and over Decline to State N/A (business, organization, etc) Please specify:
	No one is charged a fee who cannot afford to pay
Voluntary Self-Identification of Disability Status	You are not required to answer this question Decline to State Yes No N/A (business, organization, etc)
Voluntary Self-Identification of Homeless Status	You are not required to answer this question Decline to State Yes No N/A (business, organization, etc)
Do you think this conflict is motivated by hate?	Yes No
If Yes, what do you think is the basis for the bias, hatred or prejudice? (hold CTRL to select multiple entries)	Race/Ethnicity/National Origin Sexual Orientation Religion Gender Disability Age Other If "Other" please describe:
Notes to the Mediator
Active Military	Yes No
Member of Military Family	Yes No
Veteran	Yes No
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