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22287 Mullhollland 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
*
PLAINTIFF/CLAIMANT INFORMATION :
Name
*
First
Last
PLAINTIFF'S COUNSEL
Name
*
First
Last
Firm
Email
*
Address
Address Line 1
Address Line 2
City
California
Alabama
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Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
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Iowa
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Louisiana
Maine
Maryland
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Michigan
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Mississippi
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New Hampshire
New Jersey
New Mexico
New York
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Ohio
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Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
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Utah
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Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Work Phone
Fax
DEFENDANT INFORMATION:
Name
*
First
Last
Company
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DEFENDANT'S COUNSEL:
Name
*
First
Last
Firm
Email
*
Address
Address Line 1
Address Line 2
City
California
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Work Phone
Fax
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INSURANCE CARRIER:
Carrier Name
Address
Address Line 1
Address Line 2
City
California
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Claim Representative
CASE NAME
CASE NUMBER
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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 daylhalf 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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