Application for Services form

In order to schedule a mediation, we’ll need the name of your lawyer. If you don’t have a lawyer, please complete and submit the form below. If you have questions, call Joe Harrison at 515-286-2140 or email jharrison@pcbaonline.org.

Your name (required)

Your email (required)

Your day and evening phone number(s)

Your mailing address

The name of the other party's lawyer

Contact information for the other party, e.g., his/her phone number(s), mailing address, and/or email address

Your mediation deadline

Dates/times when you are available before your mediation deadline. Please list as many as possible.

Are there specific mediators you would like to request? If so, please enter their names.