Mediation Questionnaire - Law Offices of Thomas P. Miller, P.C.
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Today's Date
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I. Your Information
Full name
E-mail
Alternate telephone number
Home address
Date of birth
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Employer name
Employment position
Gross annual income
Date of marriage/civil union
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DD
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Still living with your spouse/partner?
If no longer living together, date of seperation
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DD
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YYYY
II. Your Spouse/Partner/Ex's Information
Full name
E-mail
Telephone number
Home address
Date of birth
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DD
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YYYY
Employer name
Employment position
Gross annual income
III. Children
Name
Date of birth
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DD
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YYYY
Above child living with you?
Name
Date of birth
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DD
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YYYY
Above child living with you?
Name
Date of birth
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DD
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YYYY
Above child living with you?
Name
Date of birth
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DD
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YYYY
Above child living with you?
IV. Representation
Your attorney's name
Your attorney's telephone number
Your attorney's e-mail address
Your child's attorney's name
Your child's attorney's telephone number
Your child's attorney's e-mail
V. Issues
Mark all that apply
VI. Miscellaneous
Is there a domestic violence issue
How did you find us? Please provide name of person who referred you or website.
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