LEA Mediation Information Form

Please complete this form. The Mediation Case Manager will be in contact with you once you submit the form.

Name*
First Last
Title
Email*
Phone
Student Name*
First Last
Student's Exceptionality
Select the primary exceptionality of the student.
Mediation File Number
Please choose which format you prefer for your mediation session.
Mediation can be in-person*, through online video conferencing, or by phone. When mediation is not in-person, using video conferencing (example: Zoom) may help to improve communication. However, it is up to the parties to determine which format will work best for them.
*Due to the COVID-19 pandemic, in-person mediation may not be available.
Please write in the name, title, phone number, and email address of all participants you will be bringing to your mediation.
To support a productive process, ODR suggests each party brings no more than three participants; however it is up to you to determine who will participate in the mediation.
The names of your participants will be provided to the other party; the phone number and email address of participants will be provided to the mediator only, in case of technology issues during the mediation.