Form Test INTAKE FORM - Family Mediation Please take a few moments to answer this questionnaire. This document is strictly confidential and will be seen only by our office personnel. Please mark clearly any information which you are uncomfortable discussing with the other party in mediation. Today's Date: GENERAL INFORMATION: FULL NAME: DOB: Present Address: City/town: Postal Code: Home phone: Cell phone: Email Address: Employer: LAWYER Name of Retained Lawyer (if any): Telephone: Email: Name of the person who you would like to settle issues with: Are there any legal reasons that will prevent you from communicating directly or indirectly with this person? INFORMATION FOR MEDIATOR: Is your matter in court? YesNo If yes, what stage is your preceding in? Did you and the person of this dispute ever live together? YesNo When did you begin living common-law? What was your date of marriage? When did you last separate? If your separation is recent, do you have any interest in reconciliation with this person? YesNo Are there children from this relationship? YesNo Please provide a brief background of the relationship: (Please provide a point form summary for discussion with mediator later) Please tell us something positive about the other party: Do you have Children? YesNo First Child Full Name: DOB: Age: Pronoun: Living With: Second Child Full Name: DOB: Age: Pronoun: Living With: Third Child Full Name: DOB: Age: Pronoun: Living With: Fourth Child Full Name: DOB: Age: Pronoun: Living With: Are any of the above listed children from a previous relationship? YesNo If yes, which children? Any other children not above but are still dependents: Are you currently in a new marriage/common-law relationship? YesNo If so, since when? Name of current partner: What is the highest level of education you have completed? —Please choose an option—High school or lessSome post-secondaryCollege or technical degreeUniversity degree, undergraduateOther Approximately where does your annual gross income fall? (this includes salaries, commission, bonuses, social assistance, pensions, disability benefits, rental income, spousal support received, income from business) —Please choose an option—$0-$20,000$20,000-$40,000$40,000-$60,000$60,000-$80,000$80,000-$100,000$100,000 or more Are you comfortable receiving services in English without a translator present? YesNo Do you have any disabilities you would like us to be aware of in regards to mediation? NoYes If yes, please specify: Who made the decision to end the relationship? MeOther PartyBoth If you selected "other," please specify: What are your best reasons for separating? (select all that apply) my physical abuse against partnerpartner's physical abuse against memy emotional abuse towards partnerpartner's emotional abusemy drug/alcohol problempartner's drug/alcohol problempoor/no communicationaffairfinancial mattersmy control over partnerpartner's control over medifferences in religious beliefsdifferences in culture or racedifferent goals for the futuremy poor mental healthpartner's poor mental healthphysical health problempartner's physical health problemsexuality issuesother (specify in box below) What challenges are you facing regarding the separation? (select all that apply) custody/access/parenting time of childrenfinancial supportdivision of propertydivision of debtscommunication between usmediation not going wellno lawyerlawyer not providing good adviceworry about going to courtthe emotional aspect of separationthe impact on childrenfinding a new place to livechild/spousal support being too highchild/spousal support being too lowaddictionsother (specify in box below) If you selected "other," please specify: MEDIATION PROCESS: Have you participated in mediation or arbitration before? YesNo If yes, please provide details: What do you hope to achieve from mediation? If spousal support is an issue, do you have any idea of what you want in terms of amount or duration? Are there any other issues you would like to raise or any other information you would like to provide? Consent: I understand that the information I provide in this form will be used solely for the purpose of mediation and will be kept confidential.I consent to the collection and storage of my personal information as outlined in the privacy policy.
