USTU CONFLICT MEDIATION INTAKE QUESTIONS:
1. Name:
2. Email:
3. Phone Number:
4. What is your preferred form of communication – email, phone, or in-person?
4a. If you are comfortable with email, please fill out and return this form to conflict@urbansoil.net
4b. If you would rather meet in person to fill out this form, list three times that you are available:
4c. If you would rather fill out this form over the phone, list three times that you can talk:
5. Preferred language for conflict resolution (if not English):
6. Do you have a preference for any specific mediators? The current members on the team include: Aurisha, Claire, Shaila. Please list in order of preference who you would like to request to mediate the conflict. Please only include those you feel comfortable with or think would be neutral about this issue.
The following are the questions that will be asked for our mediation intake process. Please either fill this form out yourself or arrange a time to fill it out with a mediator (see 4a-4c above) Write as much as you need to in response to each question.
1. Please describe the facts of the dispute. Include dates, events and names.
2. When did the conflict start?
3. How would you like us to describe the nature of this conflict when we approach the other person or group?
For instance, do you want us to say this is a conflict about noise, relationships, shared space, etc?
4. What are you looking to get out of mediation?
5. Describe what you feel is a fair and reasonable settlement for the dispute. What specific “asks" do you have
of the other person or group? (For example: Please stop playing amplified music after 11 pm.)
6. Are there any time restrictions or other factors we should be aware of in regards to this conflict? When are
you available to participate in mediation?
7. Is there anything else you would like us to be aware of as mediators?