Human Relations Commission

Mediation Intake Form

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Date

This is a Date field. These are the instructions.

Party One Contact Information

Contact Name

Contact Email

Contact Address

Contact Phone

Relationship to Party Two

What is your preferred language?

Do you need an interpreter? YesNo

Please describe the reason(s) you are requesting mediation. Please be specific and include as many details as possible

If needed, please attach any documentation you have.

Party Two Contact Information

Party Two Name

Party Two Email

Party Two Address

Party Two Phone

Relationship to Party One

You will be contacted by an HRC staff member to follow-up with any questions or to schedule mediation. If you do not hear back from an HRC staff member within two weeks after you have submitted your application, please call our office at (419) 245-1518. Thank you for using the City of Toledo’s Mediation services presented by the Human Relations Commission. We look forward to assisting you and others in finding an acceptable resolution.