Mediation Potential Client Questionnaire
Potential Client Information and Survey
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Email *
How did you hear about Re:Solutions Mediation? *
Required
Mediation requires that both spouses feel safe and comfortable negotiating in the same room together with a neutral mediator, are you willing and able to do this? *
Have you discussed the option of mediation with your spouse? *
Is your spouse willing to come in for a free, no-obligation consultation with you? *
Demographic Information
Full Name *
Age *
Texting/Phone Number *
What County do you reside in? *
Required
Relationship Information
Current Status
Please choose your current status: *
If married, how many years have you been married?
If separated, since when?
MM
/
DD
/
YYYY
Age(s) of any minor (Under 18) children you have with your current spouse:
Confidential Questions
Special circumstances surrounding your relationship
If you are pursuing a divorce, legal separation or dissolution, who has initiated the process?
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Please check any of the following concerns you may have about negotiating in the same room with your spouse: *
Required
Please indicate your average yearly individual income: *
Required
Issues you may bring to mediation (check all that apply) *
Required
What days and times work for you to schedule a free 30-minute consultation at my office? Check any/all that apply. *
Required
We are interested in the following flat-fee package: *
A copy of your responses will be emailed to the address you provided.
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