Dispute Intake Form

Carolyn Dragseth
American National and International Mediators
P.O. Box 7354
Wesley Chapel, FL 33545
(813) 377-3837
Carolyn Dragseth is a mediator who understands the complexities of international negotiations, transactions and mediation. We assist clients from all levels of business. From the small business owner who is expanding their product placement to a new region to the multinational corporation which requires mediation or arbitration of their disputes. We also design conflict resolution systems for our clients so that they may tailor their systems to represent the industry specific disputes that may arise between the parties.

Fill out the form below to begin the process of resolving your dispute. Fees are negotiated between participants and mediators.

Please fill out your basic information:

First Name:	(Required)
Last Name:	(R)
Phone:
Email:	(R)
Business Name (if applicable):

Please fill out the other party's basic information:

First Name:	(R)
Last Name:	(R)
Phone:
Email:	(R)
Business Name (if applicable):

Are there other parties involved in this dispute?
If so, list email addresses of other parties (one per line):

Please fill out these dispute details:

Nature of the dispute:
What date did this dispute begin?
What is the approximate monetary value of the items under dispute?
This dispute is regarding...	(R)
What do you and the other party disagree about?	(R)
Are there any things you and the other party might agree upon?
What has happened so far in this dispute? (phone calls, emails, etc.)
What do you want to get from this mediation?	(R)
Please add anything else you think it would be helpful for a mediator to know:

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