Coatesville Youth Initiative Family & Community Mediation
Self - Referral Form
All information is held in the strictest of Confidence!

This form is to be used by individuals wishing to discuss having a situation, in which they are involved, be solved through mediation services provided by the CYI Family & Community Mediation Project.

To self-refer, you are not required to check with the other party, but we do recommend, where feasible, to check with the other participants to see if they are interested in the situation going to mediation.

What is Mediation?
The CYI Family & Community Mediation Project offers an alternative approach to solving problems that develop between parents and their children. Instead of relying on schools, courts or social service agencies, family members sit down with a trained neutral mediator and work towards their own mutually agreeable solution.

The purpose of the mediation process is to assist individuals and families to work together to solve a problem or dispute and agree on a solution that is acceptable to each of them. It is voluntary – it can be ended by any of the participants at any time. It is fair – Mediators do not take sides. Instead, they provide a safe process that attempts to help the parties to communicate and identify their important needs and interests and reach an agreement. Mediation can be a quick and cost-effective way of resolving disputes and preserving relationships. More information about the process and service can be found at

Please fill out this form to request mediation. The information will help the mediator understand basic issues about you and the dispute. Filling out the form does not require you to go to mediation. Mediation will not take place unless you and the other person agrees to mediate by signing an Agreement to Mediate. There is no cost to participate in mediation.

You may also request a hardcopy by emailing us here:
If you have any questions, please call the Coatesville Youth Initiative Family & Community Mediation at 610-380-0200.
Full Name (First & Last) *

Phone Number: *

Today's Date *

Brief Description of the conflict: *

What would you like to see as a resolution? *

Are you Willing to try mediation to resolve this situation/conflict/dispute? *

Have you read the Mediation Overview sheet? *

Are you in agreement to being contacted by CYI via telephone to discuss mediation? *

Are you in agreement to being contacted by CYI via email to provide additional mediation information? *

Home Address *

The following information pertains to the 2nd person involved in the dispute/issue - Participant #2

Participant 2 Name (First & Last): *

Participant 2 Age: *

What is your relationship to this Participant (Participant #2)? *

Participant 2 Address *

Participant #2 Email *

Participant #2 Phone # *

Any other pertinent information that you would like to add?

How did you hear about the CYI Family & Community Mediation Project? *

After answering all of the questions, please hit the "submit" button to send your information to one of our Mediation Specialists. A CYI representative will be calling you for more information and to discuss your situation.

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