Client Questionnaire for Services
All parties must complete this form prior to Mediation and Investigation sessions.
Name and Contact Information: Must provide home address, Email address, 2 contact phones; Home and cell - *
Your answer
Current Employment; provide name, address, and phone number of employer, Title and years with employer
Your answer
Type of Case: Mediation of Investigation and Family Law or Probate Case; other type of issues *
Family Law Cases -- Name of children at issue in the case; Please provide names, ages, birthdates, and names of school, grade level.
Your answer
For Child Custody Mediation; What are the GOALS you want to reach in mediation? For example, joint custody for both parents, substantial time with both parents, or Supervised visits, right to move away etc...
For child custody cases or Guardianships: Is there a current child custody/Guardianship order?
If Answer was Yes to above question, please provide a summary of the Order, as well as the case number, County and State of the current order and bring copy to appointment.
For example, Joint Physical and Joint Legal custody to both parents with visits to Mother every weekend from Friday at 6pm to Sunday at 6pm. Fresno County, California Order Case No. FFL 000001234
Your answer
For child custody mediation or Probate Guardianship/Elder care cases: Are there any serious issues such as substance abuse, domestic violence, child or elder abuse, CPS or APS involvement?
If so, please briefly list them and the most recent dates of events that involved the issues named.
Your answer
For child custody cases or Guardianship Mediation: Please select the following options that you are willing to offer to the other party.
This is just a brief summary of the overall custody agreement that you will offer. Details in each category will be discussed in Mediation. Please note that for Guardianships, only the court can allow the child to be placed into the care of the natural parents, but parties can mediate visits between the parents and children.
Probate Law Cases -- Name of decedent, elder or disabled adult at issue in the case; Please provide name, ages, birthdate, date of death if applicable, and name of Care Home if applicable, primary diagnosis and prognosis.
Your answer
For Probate Cases: Is there a current Conservatorship in place?
Probate Cases - If a Conservatorship is in place or if a Petition for Conservatorship has been filed, please provide Names of all parties involved (Conservatee,Conservator) and the primary care physician - all contact information is appreciated.
Your answer
Probate Estate or Elder care Cases; Please summarize the issues that you want to Mediate or have us Investigate. Please provide dates and names of any witnesses.
For example, you may be worried about the care your elderly mother is receiving and want to mediate issues among family members and any current conservators.
Your answer
For Employment cases: Please summarize the issues that you want to Mediate or have us Investigate.
For example, you are being harassed at work and you want to mediate issues between you and your employer.
Your answer
For Contract or Landlord/Tenant disputes: Please summarize the issues that you want to Mediate or have us Investigate.
Your answer
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