Request Mediation

Please call or email the office to ensure that the date you are selecting is still available before submitting this form – drc.intake@mctx.org or 936-760-6914 x2 .

Intake Sheet

Are you requesting an In-Person Mediation at our office or a Virtual Zoom Mediation? *

In-Person Mediation

Virtual Zoom Mediation

All parties must be included in this decision.

Effective November 1, 2023, prior to scheduling a mediation or reserving a particular date/time for your mediation, the Dispute Resolution Center must receive:

1. Full payment for all parties to the mediation; or
2. Payment from the party(ies) able to pay for mediation and a Statement of Inability to Afford Payment of Court Costs from any party unable to pay for the mediation.

To pay for your mediation in order to reserve a specific date and time, use this payment form.

Requested Date (1st Choice) *

Requested Time (1st Choice) *

8:30 am

1:00 PM

Requested Date (2nd Choice) *

Requested Time (2nd Choice) *

8:30 AM

1:00 PM

Cause #

Court #

County

If other than Montgomery County

Type of Family Case Being Mediated

Divorce-Temporary, Divorce-Final, SAPCR, Modification, Enforcement

Type of Civil Case Being Mediated

Debt, Landlord-Tenant, Animal Nuisance, JP Small Claims, Auto, etc.

Petitioner

Petitioner's Name *

Petitioner's Email *

Is Petitioner Represented by an Attorney? *

Yes

No

Petitioner's Address (if pro-se)

Petitioner's Address (if pro-se)

Petitioner's Address (if pro-se)

Petitioner's Address (if pro-se)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Petitioner's Phone #

123-456-7890

Petitioner's Email

Petitioner's Attorney

Attorney's Email

Attorney's Phone #

123-456-7890

Attorney's Fax #

123-456-7890

Attorney's Address

Attorney's Address

Attorney's Address

Attorney's Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Respondent

Respondent's Name *

Respondent's Phone # *

123-456-7890

Respondent's Email *

Is Respondent Represented by an Attorney?

Yes

No

Respondent's Address (if pro-se)

Respondent's Address (if pro-se)

Respondent's Address (if pro-se)

Respondent's Address (if pro-se)

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Respondent's Attorney

Attorney's Email

Attorney's Phone #

123-456-7890

Attorney's Fax #

123-456-7890

Children (if any)

Child's Name

Primarily Living With?

Add Remove

Additional Named Parties

Party's Name

Relation To This Case

Address

Address

Address

Address

City

City

State/Province

State/Province

Zip/Postal

Zip/Postal

Party's Phone #

123-456-7890

Party's Email

Respondent's Attorney

Attorney's Email

Attorney's Phone #

123-456-7890

Attorney's Fax #

123-456-7890

Add Remove

Additional Questions

Has a protective order been requested or entered in this case? *

Yes

No

If so, against whom was it requested or entered? *

Is domestic violence alleged in this case? *

Yes

No

Is the office of the Attorney General involved? *

Yes

No

Please provide the name and direct contact information for the Attorney General involved in this case. *

Do you have a Statement of Inability to Afford Payment of Court Costs on file with a Montgomery County Court? *

Yes

No

Do you need a bilingual mediator or a translator? *

Yes

No

Translator: If yes, what language? *

Submission & Verification

Person Submitting This Application *

Contact Phone or Email *

Verification *

By checking this box, you certify that all parties have agreed to mediate on the date(s) provided.

Spam Prevention

Captcha

If you are human, leave this field blank.

After all of the parties have paid for the mediation and/or provided file-stamped copies of Statements of Inability to Afford Payment of Court Costs to the DRC-MC, you will receive confirmation of the date/time of your mediation. Please call or email the DRC-MC office at drc.intake@mctx.org or 936-760-6914 x2, if you have any questions regarding the status of a mediation request.