Apply for an intake

You can apply for an intake for yourself or for a relative, like your partner or child.

Some questions are mandatory. They are indicated with an * (asterisk).

Step 1 Who are you?

We're asking for your personal information.

By asking your address, we can find a mediator that works nearby you.
By asking your phone number and email address, we can call or email you to make an appointment.
By asking your date of birth, ew can see if you are underage. In that case, you and the mediator will discuss whether and how to involve your parents in the mediation.

Name

Prefix

Surname

Street and house number

Postcode

Place of residence

Date of birth

Phone number

Email address

I accept the General Terms and Conditions.