Bexar County Forms

2. Dispute Resolution Center
4. Mediation Request Instructions
   1. Fill out the Mediation Request Form completely. The addresses given should be mailing addresses: business addresses for a business dispute, and home (not work) address for a dispute with a private individual.
   
   2. Please fill out the "Information About Yourself" section as it relates to you.
   
   3. Please read the "Waiver and Consent" section completely. BCDRC personnel will review this document with you during the intake interview.
   
   4. If you are requesting mediation regarding court-ordered child visitation or non-payment of children's medical expenses, you must provide a copy of the court order (Divorce Decree or Suit Effecting a Parent/Child Relationship) to the BCDRC. No mediation will be scheduled until we receive a copy of the applicable court order. Please send only a photocopy of the document. We do not need the original or any supporting documentation. If there is no court order, please indicate that on your request.
6. Scheduling
   Mediation are typically scheduled at 6:00 p.m. (Central Time), Monday through Thursday. We also schedule daytime mediations Monday through Friday, if necessary. If you are unavailable particular days or times, please advise us when we interview you.
10. Your Information:
12. Your Full Name*
13. Your Mailing Address*
14. Your City*
16. Your State*
17. Your Zip Code*
18. Your Email Address
20. Mobile Number*
21. Home Number
22. Work Number
26. Other Party's Information:
28. Person/Business You are Having a Conflict With*
29. Other Party's Mailing Address*
30. Other Party's City*
32. Other Party's City State*
33. Other Party's City Zip Code*
34. Other Party's Email Address
36. Other Party's Primary Phone Number*
37. Mobile Number
38. Work Number
42. Please Tell Us About The Incident:
44. Did the incident happen in Bexar County?*

    1. Yes
    2. No

    Please Note: We only handle cases within Bexar County.
45. Date of Incident*
    Date of Incident
47. Briefly summarize the situation:*
    Please limit your explanation to 1,000 characters.
49. Is there any legal action pending in this matter?*

    1. Yes

    1. No

    "Legal action pending" means a court case has been filed in which a judge has not yet made a final decision.
50. Please explain the pending legal matter:*
52. Does this dispute involve child visitation or medical expenses?*

    1. Yes

    1. No
54. Upload Finalized Court Order
    If a court order has been finalized, please upload the order.
58. Information About Yourself
    Please provide the following information about yourself. Please Note: The following fields are required.
60. Your Age*
    -- Select One --12-1718-2425-3536-4546-6060+Unavailable
61. Your Gender*
    -- Select One --Male Female Unavailable
63. Your Ethnicity/Race*
    -- Select One --AngloAfrican AmericanHispanicNative AmericanOther
64. Your Primary Language*
    -- Select One --EnglishSpanishOther
66. Your Marital Status*
    -- Select One --SingleMarriedSeparatedDivorcedWidowed
67. Your Monthly Gross Income*
    -- Select One --UnavailableBelow - $1,610$1,611 - $2,178$2,179 - $2,745$2,746 - $3,313$3,314 - $3,880$3,881 - $4,448$4,449 or more
69. Your Educational Level*
    -- Select One --Less than High SchoolHigh School/GEDSome CollegeCollege GraduatePost - Graduate School
70. Your Employment Status*
    -- Select One --32 hours/week +Under 32 hoursNot EmployedRetired
72. Number in Your Household*
    Please type the number of people in your household.
73. How did you hear about the Dispute Resolution Center?*
77. Waiver and Consent Form
    This waiver and content form is executed in exchange for participation by the mediator in the mediation of a dispute between the above named individuals. It pertains only to the matters arising during mediation of that dispute.
    
    1. I understand that the mediator is not a legal advisor and is not to provide legal advice to any party involved in mediation. I agree to hold the said mediator harmless of any observations, suggestions or implications that he/she may make in the course or mediation. I specifically agree to obtain legal advice on any issue of interest to me from my own attorney and not to rely upon the mediator for such advice. By checking the appropriate box above, I acknowledge that there is or is not legal action pending that relates to matters involved in mediation. "Legal action pending" means a court case has been filed in which a judge has not yet made a final decision.
    
    2. I waive any right of action that I may have against the mediator for any allegation of wrongful conduct on his/her part or on the part of Dispute Resolution Center employees, while acting in the course of the mediation herein agreed to.
    
    3. I agree to the necessity that mediation be confidential and, therefore, agree that I will not call the mediators or Dispute Resolution Center employees who serve on my case to act as witnesses in any court of competent jurisdiction to testify to facts concerning or relating to the subject matter being medicated, and that I will not subpoena documents or information about my case which may have been retained in any case file. I understand that no subpoenas, citations, writs or any other process shall be served at or near the location of any mediation session. I further agree that I will not utilize any voice recording device during the mediation session.
    
    4. I agree treat anything said by opposing party as part of an offer to compromise and settle the dispute being mediated. I further agree that statements made during mediation shall be treated as offers to settle and shall not be admissible should this matter become a matter in litigation.
79. Texas law requires the reporting of abuse or neglect of children, the elderly and the disabled. Should such information surface during mediation, it will be reported to the proper authorities as will any serious threats of imminent danger or physical harm.
81. Is litigation pending?*

    1. Yes

    1. No
83. Consent to Terms*
    By typing my name in the above field, I consent to these terms and waive the rights herein specified, and I know that I have the right to consult legal counsel before executing this document.
Leave This Blank:


85. 1. Receive an email copy of this form.
86. Email address

    This field is not part of the form submission.

87. Submit Submit and Print

* indicates a required field