Client Information Form

Please complete this form to provide us the information we need to contact you about your dispute.

Are you filling this form out for someone else?

Contact you first? Put in your details in the contact fields if you want us to contact you first.
Contact them? Put their details in the contacts fields if you want us to contact them directly. Put your name and any other details in the Referred By field in case we need to check in with you.

First name

Last name

Phone number

Email*

Gender

City

State/Region

Name of the other Person or Organisation

Please enter the name of the person, people or organisation are you looking for dispute resolution help for.

Referred By

Please let us know who referred you or if you are the referrer filling out this form for someone else put your details here. Provide as much or as little information as seems appropriate to you e.g. organisation name if we don't need to get back to you or your name and contact details if you would be available for us to check in regarding this referral.

Dispute Information*

Very briefly outline what sort of dispute this is e.g neighbour, family member, workplace etc

Cultural Aspects?

In your opinion, does the dispute have anything to do with your culture, religion, language, sexuality, abilities, or other characteristic?

Safety *

Are there any safety concerns, protection orders or anything similar we should know about?