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ADR Screening testing
sterling
2020-11-13T18:35:51+00:00
ADR Screening (testing)
Step 1 of 4
25%
Submitted By
*
Who is completing this form?
Plaintiff:
Person who filed.
Defendant:
Person whom case is being filed against.
Select One
Plaintiff
Defendant
Attorney for Plaintiff
Attorney for Defendant
Mediator
Other
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.
Select the county
Appling
Atkinson
Bacon
Baker
Baldwin
Banks
Barrow
Bartow
Ben Hill
Berrien
Bibb
Bleckley
Brantley
Brooks
Bryan
Bulloch
Burke
Butts
Calhoun
Camden
Candler
Carroll
Catoosa
Charlton
Chatham
Chattahoochee
Chattooga
Cherokee
Clarke
Clay
Clayton
Clinch
Cobb
Coffee
Colquitt
Columbia
Cook
Coweta
Crawford
Crisp
Dade
Dawson
De Kalb
Decatur
Dodge
Dooly
Dougherty
Douglas
Early
Echols
Effingham
Elbert
Emanuel
Evans
Fannin
Fayette
Floyd
Forsyth
Franklin
Fulton
Gilmer
Glascock
Glynn
Gordon
Grady
Greene
Gwinnett
Habersham
Hall
Hancock
Haralson
Harris
Hart
Heard
Henry
Houston
Irwin
Jackson
Jasper
Jeff Davis
Jefferson
Jenkins
Johnson
Jones
Lamar
Lanier
Laurens
Lee
Liberty
Lincoln
Long
Lowndes
Lumpkin
Macon
Madison
Marion
McDuffie
McIntosh
Meriwether
Miller
Mitchell
Monroe
Montgomery
Morgan
Murray
Muscogee
Newton
Oconee
Oglethorpe
Paulding
Peach
Pickens
Pierce
Pike
Polk
Pulaski
Putnam
Quitman
Rabun
Randolph
Richmond
Rockdale
Schley
Screven
Seminole
Spalding
Stephens
Stewart
Sumter
Talbot
Taliaferro
Tattnall
Taylor
Telfair
Terrell
Thomas
Tift
Toombs
Towns
Treutlen
Troup
Turner
Twiggs
Union
Upson
Walker
Walton
Ware
Warren
Washington
Wayne
Webster
Wheeler
White
Whitfield
Wilcox
Wilkes
Wilkinson
Worth
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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 afraid of the other party?
*
Yes
No
Do you have any concerns when the other party does not get his/her/their way?
*
Yes
No
Have you or the other party ever tried or threatened to:
*
Check all that apply
Commit suicide
Harm the other
Harm children
Harm family
Harm pets
Use a weapon
None of these apply
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
Untitled
Phone
Comments
This field is for validation purposes and should be left unchanged.
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