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.

Fill in this form to request mediation service. Someone will get back to you as soon as possible.

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Name: *

E-Mail Address: *

Phone Numbers:

Mailing Address:

Other Party's Lawyer:

Other Party's Contact Info:

Mediation Deadline:

Dates/Times of Availability:

NameS of Specific MediatorS Requested:

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