Dispute Resolution Center

Family Case Intake

New Family Intake

Please fill out all relevant information.

If you have any questions, please call Jolynn at 845-372-8771 x5001.

Fields marked * are required.

Your name

Your email address

Your phone number

Your address

Address line 2

City

State

Zip

About the Matter

Who referred you to mediation at the DRC?

Other Party (if applicable)

Name of the other party

Other party's email address

Other party's phone number

Other party's address

Address line 2

City

State

Zip

Additional Information

Describe the issues that you are hoping to resolve.

What is your relationship to the other party?

In which county do you live? If you do not live in New York State, choose the county where the other party lives.

Is this case pending in court? If yes, which court?

Docket Number

If this case is pending in court, what is your next appearance date?

Primary Language

Date of Birth

Race

Sex

Educational Attainment

Employment

Household Income

Veteran Status

Disability Status

Number of Persons in Household

Child 1 First & Last Name - M/F - DOB (If not applicable, write n/a)

Child 2 First & Last Name - M/F - DOB

Child 3 First & Last Name - M/F - DOB

Child 4 First & Last Name - M/F - DOB

Additional Questions

Has the other party been told that you would be reaching out to DRC for mediation?

Secondary phone number

Is there an Order of Protection issued against any party by any court?

Is there an open CPS case on any party?

How did you hear about mediation and DRC?

Would you like to receive our newsletter?

Yes