Please fill in the following form and click on the "Submit Referral" button to have your case sent to ADR for mediation. We will do all of the setup and scheduling.

1.	Date Referred:
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2.	Case Name:
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3.	Referred By:
	Name:
	Claim/File:
	Telephone:
	Fax:
	Email:
	Company:
	Address:
	Client/Insured:
	Type:	Plaintiff Defendant Other
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4.	Participants:	Type: Plaintiff Defendant Other Represented By: Telephone: Fax: Email: Company: Address: Type: Plaintiff Defendant Other Represented By: Telephone: Fax: Email: Company: Address: Type: Plaintiff Defendant Other Represented By: Telephone: Fax: Email: Company: Address:
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5.	Case Description:
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6.	Special Instructions:
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7.	Fees Paid By:
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8.	Mediator:	No Preference Preference If "Preference" is selected, please elaborate:
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9.	Trial Date:
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10.	Location Preference:	New Orleans Baton Rouge SW Louisiana North Louisiana Northshore Other If "Other" is selected, please elaborate:
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11.	Have all parties agreed to mediate? Yes     No If no, please explain:
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