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Mediation Intake Form
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* Indicates required question
Email
*
Your email
Name: First/Last (Party 1)
*
Your answer
Date of Birth (Party 1)
*
MM
/
DD
/
YYYY
Phone Number (Party 1)
*
Your answer
Full Address (Party 1) {cannot be a PO Box}
*
Your answer
Occupation (Party 1)
*
Your answer
Name: First/Last (Party 2)
*
Your answer
Date of Birth (Party 2)
*
MM
/
DD
/
YYYY
Phone Number (Party 2)
*
Your answer
Email (Party 2)
*
Your answer
Full Address (Party 2) {cannot be a PO Box}
*
Your answer
Occupation (Party 2)
*
Your answer
Current Marital Status
*
Your answer
Please list all of your children (Name | age | lives with)
*
Your answer
Other adults or children in your home (Name | Age | Relationship to you)
Your answer
Are you currently working with or have an attorney?
*
Yes
No
Attorney Info (Name | Email | Phone # | Address) *if applicable
Your answer
Are you currently involved in a lawsuit or have an upcoming court hearing? *Please provide any information I should be aware of
*
Your answer
Emergency Contact: (Name, Relationship, Phone #)
*
Your answer
What do you hope to focus on in mediation?
Pre or Post-marital agreements
Dissolution of marriage/separation/divorce
Domestic partnerships
Stepfamily blending
Custody or Coparenting plans
Inheritance planning/discussions
Parents and grown children conflict
Other:
If the focus is separation and custody, please provide
(marriage date, separation date, and divorce date)
Your answer
What are the current legal and/or parental care arrangements? *if applicable
Your answer
Are there any safety concerns regarding any parties in the family/relationship?
*
Your answer
Are both parties willing to meet for mediation?
Your answer
What do you hope to resolve in mediation? Please include any other additional information if necessary:
Your answer
How did you hear about me?
*
Your answer
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