General Mediation Request

Please use this information form to request mediation from the UALR William H. Bowen School of Law clinical program.

Name of person requesting mediation*
FirstLast
Address*
Street AddressCityStateZip Code
Phone*
Second phone
Email
Do you have an attorney?
- Yes
- No
If your answer is Yes, then fill out the next two questions, please. An attorney is not required to obtain mediation assistance.
Attorney's name
FirstLast
Attorney's phone number
Summary of issues to be discussed in mediation*
Other party in the case*
FirstLast
Address
Street AddressCityStateZip Code
Phone*
Second phone
Email
Does the other party in the case have an attorney?
- Yes
- No
- I don't know
If your answer is Yes, then fill out the next two questions, please. An attorney is not required to obtain mediation assistance.
Attorney's name
FirstLast
Attorney's phone number
How did you hear about us?