Full name of spouse: Spouse's address (if different from yours): Place and date of marriage: Date of separation (if applicable): Names and birthdates of minor children (if applicable): Your employer/place of work: Your spouse's employer/place of work: Case name/number/location of any pending court action (if applicable): Date(s) of any schedule hearings/trial (if applicable): Name of spouse's attorney (if known): Preferred dates/times for initial consultation:

Full name of future spouse: Future spouse's address (if different from yours): Place and date of wedding: Your employer/place of work: Your future spouse's employer/place of work: Name of future spouse's attorney (if known): Preferred dates/times for initial consultation:

Your Business Name or Employer / Former Employer / Prospective Employer: Address of Your Business or Employer / Former Employer / Prospective Employer: Names of any other involved parties: Preferred dates/times for initial consultation: Nature of your employment matter (e.g., employment agreement review, preparation, or negotiation; small business counseling and advice; discrimination (race, color, religion, national origin, sex, pregnancy, childbirth, sexual orientation, gender identity, disability, age); wrongful termination, retaliation, harassment; wage/benefit dispute; breach of employment agreement, non-competition agreement, non-solicitation agreement; misappropriation of trade secrets; negligent hiring, supervision, and retention; fraud; defamation; assault and battery; invasion of privacy; tortious interference; filing or defending an EEOC Charge; dispute avoidance and resolution. Is there a pending lawsuit, EEOC Charge, or other proceeding of any kind? If yes, provide the case name, number, court, agency, and date of filing:

Date of Accident: Location of Accident: Names of other parties involved: Name of your insurance company: Name(s) of insurance company(ies) for any other party:

Case name/number/location of any pending court action (if applicable): Date(s) of any schedule hearings/trial (if applicable): Nature of the Matter: (e.g., business dispute, unfair trade practices, real estate dispute / partition proceeding, catastrophic injury, civil rights, construction dispute, defamation (libel or slander), fraud, insurance coverage dispute, negligence, personal injury, product liability, trust or estate dispute, breach of fiduciary duty, will contest) Names of any other involved parties: Preferred dates/times for initial consultation:

Clark Hering is an NCDRC Certified Mediator for Superior Court (MSC) and Dan Koenig is an NCDRC Certified Mediator for Superior Court (MSC) and Family Financial (FFS) matters. Are you inquiring about Clark, Dan,or either one of them serving as a mediator in a matter in which you are involved? Nature of the Matter: (e.g., family law, employment law, motor vehicle accident, business dispute, real estate dispute, trust or estate dispute, breach of contract, or other): Names of all parties involved and their counsel (if applicable): Names of any insurance companies involved: Is this a voluntary or court-ordered mediation? Preferred dates/times for mediated settlement conference:

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