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Home
About
Practice Areas
Mediation
Our Team
Contact Us
Mediation Intake Form
PERSONAL INFORMATION
Name
*
First Name
Last Name
Maiden Name (if applicable)
Email
*
Phone
*
(###)
###
####
Residential Address
*
County of Residence
*
Mailing Address (if different)
Date of Birth
MM
DD
YYYY
Date of Marriage
Date of Separation
If not applicable, please so indicate
Job Title
Annual Income
Pre-tax dollars
Highest Level of Education Completed
INFORMATION ABOUT YOUR CHILDREN
Full Names and Birth Dates of Children
(if any child is adopted, or not a biological child of one or either spouse, please indicate)
Residential Address of Children
PRIOR LEGAL PROCEEDINGS
Are there now or have there ever been any protection orders or restraining orders between you and the other party?
*
Yes
No
If so, what court?
When was the most recent order entered?
What is the expiration date of that order?
Have there been any other court actions between you and the other party
*
Yes
No
If so, in what court?
What orders has the Court entered?
Has a case already been filed in this matter?
*
Yes
No
If so, in what court?
Case number
Have you signed any paperwork regarding this case? If so, please describe:
Are there any Court dates currently scheduled?
Has the Department of Human Services been involved with you, the opposing party or any child(ren) at issue? If so, when and why?
MEDIATION PREPARATION
What would constitute a "successful" mediation for you?
What are your top three priorities for mediation?
What do you believe to be the other party's top priorities for mediation?
What are the biggest roadblocks to healthy communication between you and the other party? and/or What are the biggest ways your priorities conflict?
What are some keys to effective communication/handling conflicting priorities with the other party?
Do you have any questions about the mediation process?
HOW WERE YOU REFERRED TO US?
*
I am a previous client
Bar Association
Website
Internet search
Friend/Family
Another attorney
Other
Name of Referral Source
Electronic Signature
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Thank you!
