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 -
Current Employment; provide name, address, and phone number of employer, Title and years with employer
Type of Case: Mediation of Investigation and Family Law or Probate Case; other type of issues
Child Custody Mediation
Child Custody Investigation
Probate Guardianship Mediation
Probate Guardianship Investigation
Probate Estate Mediation
Probate Estate Investigation
Contract or Landlord/Tenant dispute
Legal Document Assistance
Full Marriage Settlement Agreement - Assets, Retirement, Child custody etc...
Research/Writing/Attorney assistance services
Business Formation assistance
Family Law Cases -- Name of children at issue in the case; Please provide names, ages, birthdates, and names of school, grade level.
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...
Better co-parenting communication
Less conflict at exchanges
End the Current Supervised visits
Helping the children transition, lessen their stress
Less custodial time with the other parent
Seeking Joint Legal and Physical custody
Seeking Right to Move out of the County or our of the State
More custodial time with the children
Safer Home for the children; Seeking protections for the children during visits
Assure Health, Safety and Welfare; Seeking Counseling or Substance Abuse testing of other parent
Preventing Domestic Abuse and Children's exposure to domestic abuse
For child custody cases or Guardianships: Is there a current child custody/Guardianship order?
Yes - Please name County and State of Order and bring to appointment.
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
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.
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.
Joint Physical custody - Both can have the children in their care for a substantial period of time.
Sole Physical custody to me - Only I can have the children for substantial periods of time, but the other party can have some visitation.
Joint Legal Custody - Both parties can make legal, educational, and medical decisions for the children. We will discuss the issues amicably and make decisions together, however.
Sole Legal Custody - Only I can make legal, medical and educational decisions for the children. I will inform the other parent about my decision, however.
Shared Holidays and school breaks. Details to be discussed in Mediation.
No shared holidays or school breaks.
I am offering only Supervised Visits due to issues that pose a detriment to the child/ren.
I want to reserve the right to move the children out of the County or the State with a notice to the other party.
I want to add special conditions such as substance abuse counseling/testing, or other risks posed by the other parent.
I want to add conditions regarding child support.
I want to add conditions regarding assets and division of property.
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.
For Probate Cases: Is there a current Conservatorship in place?
Yes - please provide case information in next section
Pending in Court - already filed (Provide County and case information in section below.)
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.
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.
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.
For Contract or Landlord/Tenant disputes: Please summarize the issues that you want to Mediate or have us Investigate.
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