Form

DUFFEE + EITZEN MEDIATION FORM

SECTION I.

CASE/CAUSE NUMBER*

TYPE OF CASE*

PETITIONER'S NAME & EMAIL*

RESPONDENT’S NAME & EMAIL*

CHILDREN'S NAMES (IF APPLICABLE)

USE ENTER KEY TO SEPARATE ANSWERS IF THERE ARE MULTIPLE CHILDREN

JUDICIAL DISTRICT COURT NUMBER*

COUNTY, TEXAS*

SECTION II.

-For the purposes of this form:

"PT" stands for Petitioner

"RD" stands for Respondent

-When multiple items are required use the enter key within the specified box to separate the answers

PETITIONER (PT)

PETITONER ATTORNEY INFORMATION *

PLEASE LIST: ATTORNEY NAME AND EMAIL

PT FIRM INFORMATION. (OPTIONAL)

PLEASE LIST: 1. FIRM NAME 2. MAILING ADDRESS 3. PHONE and 4. FAX

PT PARALEGAL INFORMATION (OPTIONAL)

PLEASE LIST PARALEGAL NAME AND EMAIL

RESPONDENT (RD)

RESPONDENT ATTORNEY INFORMATION*

PLEASE LIST: ATTORNEY NAME AND EMAIL.

RD FIRM INFORMATION (OPTIONAL)

PLEASE LIST: 1. FIRM NAME 2. MAILING ADDRESS 3. PHONE and 4. FAX

RD PARALEGAL INFORMATION (OPTIONAL)

PLEASE LIST: PARALEGAL NAME AND EMAIL

SECTION III

MEDIATION INFORMATION

MEDIATION DATE REQUEST*

Year/Month/Day

HALF DAY OR FULL DAY?*

HALF DAY=4 HOURS; FULL DAY=8 HOURS

MEDIATION LOCATION OPTIONS*

Choose from our office, zoom, or off site. Note: If you choose "Off Site" Please provide off-site location address in the box labeled "ADDITIONAL INFORMATION"

DUFFEE + EITZEN MEDIATOR REQUEST

SELECT A DUFFEE + EITZEN MEDIATOR

ADDITIONAL INFORMATION

Example: "I would like the mediation to be located off site at ___"

BEST EMAIL TO CONTACT YOU*