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22287 Mullholland Highway, #185, Calabasas, CA 91302
wfassberg@fassbergmediation.com
818.222.5025
Fassberg Mediation Services
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Professional Background
Intake Form
Home
Professional Background
Intake Form
Intake Form
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Are you an Attorney or a Client
Attorney
Client
Name
*
First
Last
Email
*
Lawsuit Filed?
Yes
No
Case #
Mediation to be Held Online?
Yes
No
PLAINTIFF/CLAIMANT INFORMATION
Plaintiff/Claimant Name
*
Plaintiff's Counsel Name
*
Firm
Email Address
*
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Work Phone
Fax
DEFENDANT INFORMATION
Defendant's Name
*
Company
DEFENDANT'S COUNSEL:
Defendant's Counsel Name
*
Firm
Email
*
Address
Street Address
Address Line 2
City
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Delaware
District of Columbia
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Maryland
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North Carolina
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Northern Mariana Islands
Ohio
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Pennsylvania
Puerto Rico
Rhode Island
South Carolina
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Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone
Fax
INSURANCE CARRIER
Carrier Name
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
Claim Representative
CASE NAME
CASE NUMBER
GENERAL QUESTIONS
Have all parties agreed to the assignment of Wendy Fassberg as the neutral?
How many hours would you like to allocate to this matter? (mediations are booked on a full day/half day basis)
How will the fees be split?
Are there any time constraints relative to commencement or completion of the mediation?
What type of case is this (e.g. Real Estate, Construction, Contract, etc.)?
Please provide any other pertinent information below.
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