Organisation Details

Organisation Name *

Date of Request *

ABN *

ACN (if your organisation has one)

Industry *

Address of Mediation (in-person only)

Street address

City

State

Postcode

Only needed if the mediation will be held in person. Leave blank for online or if you are not sure yet.

Your First Name *

Your Last Name *

Position title *

Email Address *

Phone Number *

What is your role in this mediation? *

Who do we send the invoice to? *

The requestor (the person filling out this form)Different person (but internal)EAP (Employee Assistance Program)

Account and Billing Details

Name (First)

Last Name

Accounts Role / Title

Accounts Email

Accounts Phone Number

Address on Invoice

Street address

City

State

Postcode

What is the name of your EAP?

Do you have a procurement number or reference code for the invoice *

YesNo

Please provide the relevant code

Mediation / Facilitation Participants

Participants are the people you want to attend a mediation with us. We will not contact the participants without your approval.

Name

Position / Title

Phone Number

Support person option explained?

Post-Mediation Contact Person

For the Participants

This is the person who will be responsible for the participants post-mediation. This person is usually the participants Supervisor or Manager. If there is more than one (for example the participants report to two separate people, then please include both names). We can have 2 or more people attending the intake. They will be invited to an intake session where we listen to what has happened, and get a deeper understanding of the context and challenges. We talk about the process, clarify expectations and talk about what happens after the mediation is completed. This person does not usually attend the joint session (mediation).

Name

Position / Title

Phone number

Scheduling and Logistics

Preferred date range for intake sessions (1:1 with the mediator)

Location of mediation *

OnlineIn person - on site (you will organise an appropriate room)In person - off site (may accrue additional fees)Not sure yet

Parking details (if in person)

Can you cover travel and accommodation costs if a local mediator is not available or preferred?

YesNoPlease discuss with us first

If in person, are you able to provide lunch and water for the mediator and participants?

YesNoNot applicable (online)

Preferred mediator (optional)Emverio will allocate a mediator if you don't have a preference. All our mediators are experienced, accredited and take part in regular professional development.

Summary of Workplace Concerns

Brief history of the issues *

How would you categorise the concerns raised between the participants? *

Communication and other Interactions (undermining, tone, body language, style, avoidance, withdrawal, escalation) Working relationship and interpersonal tension (strained, loss of trust, lack of respect, different values, reactivity)Role, Responsibility and Boundaries (role clarity, decision making, task ownership, expectations, changes)Performance and Work (feedback and supervision issues, missed deadlines, quality concerns, workload pressures)Leadership, Supervision Issues (micro-management, inconsistency, lack of support / guidance, decision making conflicts)Psychosocial & Wellbeing Factors (stress, burnout, psychological safety, emotional strain, personal issues, fatigue)Equity, Fairness and Treatment (unfair treatment, perceived bias or favouritism, being targeted, procedural fairness)Cultural differences (creating norms for example: gender / sexual / generational orientation and hierarchy challenges) Organisational / structural challenges (remote / hybrid WFH challenges, team culture / dynamics, use of technology)

Are there any psychosocial risks, neurodiverse or cultural considerations we should know about?

Have there been other previous interventions? *

Coaching / CounsellingDisciplinary action (i.e warnings issued)Internal informal discussions / mediationPerformance ManagementWorkplace InvestigationNone - this is the first intervention

What are your top three expectations? Tick most relevant *

Improved working relationshipClarification of roles, boundaries or expectationsRestoration of effective communication Resolution of a specific issue or incidentRisk reduction / prevention of escalation

Is there anything else you would like us know?For example: why do you think they have been unable to resolve their differences?

Please upload any further material

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Payment Terms and Cancellation Policy

Please read these terms before you submit this form.

Fees. A standard two-person workplace mediation is $3,200 + GST for approximately 8 hours, with roughly 1 hour added per extra participant. Where a matter requires more or less time, the hourly rate is $400 + GST. Travel is charged at $120 + GST per hour. Off-site room hire, where arranged by us, is charged at cost. Not-for-profit rates are $2,800 + GST per mediation and $380 + GST per hour beyond 8 hours.

Payment. Invoices are due 14 days from the date of invoice. Interest of 10% per annum accrues from the due date on any unpaid invoice. If an invoice remains unpaid after 30 days the matter may be referred to debt collectors, and costs incurred may be payable by you or recovered through the courts or tribunals. If there is a dispute about our service or fees, you agree to pay 50% of the outstanding invoice in good faith until the matter is resolved.

Cancellation of joint sessions. If you cancel your mediation within 3 days of the scheduled joint session, a 100% fee applies. Cancellations made before that point are not charged. We encourage rescheduling rather than cancelling, so that matters are not escalated to more formal and more expensive processes.

Privacy. We handle the information you provide in line with our Privacy Policy.

I have read and accept the Payment Terms and Cancellation Policy above, and I am authorised to accept them on behalf of my organisation. *

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