Mediation Order Form

To schedule your mediation, please fill out the Mediation Order Form below and submit to Baytown DRC and then call us to schedule your mediation date and time. Phone: 281.424.6466

1. Contact information for person completing case information sheet:

Name*

Address*

City, State, Zip*

Email Address*

Telephone*

Fax

State Bar No.

NAMES OF PARTIES IN CASE

Person or entity completing sheet is:

Attorney for Plaintiff / Petitioner Pro Se Plaintiff / Petittioner Title IV-D Agency Other

If other was chosen, please list type of person or entitly

Plaintiff(s) / Petitioner(s) - List all named separated by commas

Defendant(s) / Respondent(s) - List all names separated by commas

Additional Parties in Child Support Case:

Custodial Parent

Non-Custodial Parent

Presumed Father

2. Indicate case type, or identify the most important issue in the case (select only one)

CIVIL

Contract

Debt / Contract

Consumer / DTPA Debt / Contract Fraud / Misrepresentation Other Debt / Contract

Forclosure

Home Equity - Expedited Other Foreclosure

General Contracts

Franchise Insurance Landlord / Tenent Non-Competition Partnership Other type of general contract

Injury or Damage

General Injury or Damage

Assault / Battery Construction Defamation Motor Vehicle Accident Premises Other type of assault / battery

Malpractice

Accounting Legal Medical Other type of malpractice

Product Liability

Asbestos / Silica Other type of Product Liability

Real Property

Real Property

Eminent Domain / Condemnation Partition Quit Title Tresspass to Try Title Other type of real property

Related to Criminal Matters

Related Criminal Matter

Expunction Judgment Non-Disclosure Seizure / Forfeiture Writ of Habeas Corpus - Pre-indictment Other type of criminal dispute

Employment

Employment Matters

Discrimination Retaliation Termination Works'Compensation Other type of employment dispute

Miscellaneous Civil

Misellaneous Civil Dispute

Administrative Appeal Antitrust / Unfair Competition Code Violations Foreign Judgment Intellectual Property Lawyer Discipline Perpetuate Testimony Securities / Stock Tortious Interference Other

Tax

Tax

Tax Appraisal Tax Delinquency Other Tax

If Other Chosen

If other was chosen from any of the above Civil categories, please list other civil dispute

PROBATE AND MENTAL HEALTH

Probate / Wills / Intestate Administration

Dependent Administration Independent Administration Other Estate Proceedings Guardianship - Adult Guardianship - Minor Mental Health Other probate and mental health

If other type of probate and mental health chosen, please list

FAMILY LAW

Marriage Relationship

Annulment Declare Marriage Void Divorce with Children Divorce - No Children

Post-Judgment Actions (non-Title IV-D)

Enforcement Modification - Custody Modification - Other

Title IV-D

Enforcement / Modification Paternity Reciprocals (UIFSA) Support Order

Other Family Law

Enforce Foreign Judgment Habeas Corpus Name Change Protective Order Removal of Disabilities of Minor Other family law

Parent - Child Relationship

Adoption / Adoption with Termination Child Protection Custody or Visitation Gestational Parenting Grandparent Access Parentage / Paternity Termination of Parental Rights Other parent-child relationship

If other type of family law was chosen, please list below

Select

Option Option Option

3. Indicate procedure or remedy, if applicable (may select more than one)

Choose Procedure or Remedies (may choose more than one)

Appeal from Municipal or Justice Court

Arbitration-related

Attachment

Bill of Review

Certiorari

Class Action

Declaratory Judgment

Garnishment

Interpleader

License

Mandamus

Post-judgment

Prejudgment Remedy

Protective Order

Receiver

Sequestration

Temporary Restraining Ord/Injunction

Turnover

4. Indicate damages sought (do not select if a family law case)

Indicate damages sought (do not select if it is a family law case)

Less than $100,000, including damages, penalties, expenses, pre-judgment interest, & attorney fees Less than $100,00 and non-monetary relief Over $100,000 but not more than $200,000 Over $200,000 but not more than $1,000,000 Over $1,000,000

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