ADR Screening testing

Submitted By*
Who is completing this form? Plaintiff: Person who filed. Defendant: Person whom case is being filed against.
Mediator Email*
County where case is filed*
Choose the county in which the case is filed. This may or may not be the county in which you live. This information can be found at the top of the paperwork filed with the court.
Case Number
The case number assigned by the Clerk of Court. May be left blank if unknown.
Full Name*
Name as it appears on the paperwork filed by the court.
Name*
First Last
Phone*
Best number to reach you if ADR Staff has further questions. If possible, provide phone number for which it is safe for a member of the ADR Court program to contact you if needed.
Email*
Best email address for the ADR Program to contact you and send correspondence.
Email*
Enter Email Confirm Email
Address*
Best address for sending mail. This address does not have to match that which is on file for the court. However, please note it will not change the address on file with the court.

Street Address Address Line 2 City State ZIP Code

Is there now or has there ever been a protective order, restraining order or stalking order sought or issued for you and/or the other party?*
- Yes
- No
Is the Division of Family and Children Services (DFCS) and/or Adult Protective Services (APS) involved in this case?*
Does not include requests for financial assistance.
- Yes
- No
Have you or the other party ever been arrested for an act of violence or making threats against another person?*
- Yes
- No

Are you currently living in the same home with the other party?*
- Yes
- No
If so, do you think you would feel safe in returning home after discussing the issues in your case in mediation?
- Yes
- No
Are there any other concerns about your safety?
For immediate concerns, please call 911.
- Yes
- No
Please explain your safety concerns
Phone
This field is for validation purposes and should be left unchanged.