Mediation Information Sheet
TO BE PROVIDED TO THE MEDIATOR PRIOR TO THE FIRST SESSION
Email address *
What is your mediator's name? *
Your answer
Your name: *
Your answer
Address: *
Your answer
City, State, Zip: *
Your answer
Cell Phone: *
Your answer
Other Phone (please specify type):
Your answer
Email Address: *
Your answer
Other Parent's Name: *
Your answer
Other Parent's Address:
Your answer
Other Parent's City, State, Zip:
Your answer
Other Parent's Phone (indicate if not cell):
Your answer
Other Parent's Email:
Your answer
Parent 1 (you) DOB: *
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Parent 2 (other parent) DOB:
MM
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DD
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YYYY
Child 1 First, Middle, Last Name: *
Your answer
Child 1 DOB: *
MM
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DD
/
YYYY
Child 1 School: *
Your answer
Child 1 Grade: *
Your answer
Child 1 Extra Curricular Activities: *
Your answer
Child 1 Special Needs: *
Your answer
Child 2 First, Middle, Last Name:
Your answer
Child 2 DOB:
MM
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DD
/
YYYY
Child 2 School:
Your answer
Child 2 Grade:
Your answer
Child 2 Extra Curricular Activities:
Your answer
Child 2 Special Needs:
Your answer
Child 3 First, Middle, Last Name:
Your answer
Child 3 DOB:
MM
/
DD
/
YYYY
Child 3 School:
Your answer
Child 3 Grade:
Your answer
Child 3 Extra Curricular Activities:
Your answer
Child 3 Special Needs:
Your answer
Child 4 First, Middle, Last Name:
Your answer
Child 4 DOB:
MM
/
DD
/
YYYY
Child 4 School:
Your answer
Child 4 Grade:
Your answer
Child 4 Extra Curricular Activities:
Your answer
Child 4 Special Needs:
Your answer
Names and ages of all half-siblings, step-siblings, or other children in the home:
Your answer
Have you attended the Children in the Middle Class? If yes, please email a copy of your certificate of completion to: iowamediationcenter@gmail.com, completion is mandatory before mediation. *
Required
If you have not completed Children in the Middle Class, but are currently registered, please select the date you are registered for this class.
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DD
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Where do you children live now?
Your answer
Do you want to mediate? If so, why? If not, why not? *
Your answer
What are your goals for mediation? *
Your answer
Is there any reason for you to be afraid of the other party in this case? *
Your answer
Has the other party ever threatened you or your children with physical violence? *
Your answer
Has the other party ever used any type of physical force towards you or your children? (i.e. hitting, pushing, chocking kicking, etc.) If yes, explain in detail including dates. *
Your answer
Has the other party ever prevented you from leaving a situation when you wanted to? If yes, please describe. *
Your answer
Has there been any physical violence due to the use of drugs or alcohol? *
Your answer
Do you have any issues with mental health, substance abuse, addiction, physical or cognitive impairments or other issues that limit your parenting abilities? If so, please describe. *
Your answer
Does the other parent have any issues with mental health, substance abuse, addiction, physical or cognitive impairments or other issues that limit their parenting abilities? If so, please describe. *
Your answer
Have you ever called the police to protect yourself or your children from the other party? If so, please describe. *
Your answer
Have you or the other party ever been convicted of domestic violence or a related offense? If yes, please list who, when, what Court and if they are on probation or parole. *
Your answer
Have you ever had a restraining order against the other party? if yes, please state when and if it is still in effect. *
Your answer
Have you ever stayed in a shelter to protect yourself or your children from the other party? If yes, when? *
Your answer
Are you scared to answer any of these questions for any reason? If yes, why? *
Your answer
Has the other party ever threatened to keep or harm the children or any other friends or family members if you did not cooperate with them? *
Your answer
What kind of body language signs does the other party exhibit if they are angry, upset, or stressed? *
Your answer
What kind of body language signs do you exhibit if you are angry. upset, or stressed? *
Your answer
If you begin to feel uncomfortable during the mediation, would you be able to ask the Mediator for a break or ask to speak to the Mediator in private? *
Required
Do you or the other party ever have problems controlling your emotions when you get angry, upset, or stressed? *
Your answer
When you look back over time, how were decisions made in your relationship? Please provide examples. How did you feel about the way decisions were made? *
Your answer
Mediators are not decision makers, all decision making must be done through mutual agreement between parents. Mediators facilitate discussion, provide information for additional resources/supports and help brainstorm possible solutions. Who are the decision makers during mediation? *
Your answer
During your relationship, how did you and the other party handle your money? *
Your answer
Child support is not determined through mediation. What concerns do you have about child support? *
Your answer
During mediation, you and the other party MAY meet in the same room to talk about all the issues that need to be resolved. Do you have any concerns about sitting in the same room with or mediating with the other party? *
Your answer
Would you feel more comfortable if your attorney or a support person(s) was present with you during the mediation sessions? If so, who might you consider bringing to support you during mediation. *
Your answer
Are there any guns or other weapons in either of your homes? If so, please describe how these are stored to ensure child safety. *
Your answer
Has the other party ever damaged or destroyed your property or your children's property? If so, what happened? *
Your answer
Has the other party ever hurt or threatened to hurt or kill your pets or your children's pets? Do you have any concerns about the safety of your pets? *
Your answer
Has the other party ever threatened to hurt or kill themselves? Has the other party ever intentionally hurt themselves, attempted suicide or received treatment for suicidal tendencies? If so when, and please describe. What specific concerns do you have? *
Your answer
Have you ever intentionally hurt yourself or suffered from suicidal thoughts, made suicidal statements, or received treatment for suicidal tendencies. If so when, and please describe. Do you feel you need any additional assistance in receiving services to help you with these concerns? *
Your answer
Have any of your children ever threatened to hurt or kill themselves? Have any of your children ever intentionally hurt themselves, attempted suicide or received treatment for suicidal tendencies? If so when, and please describe. Do you feel any additional assistance is needed for your child/children in this area? *
Your answer
Is there or has there ever been an open abuse or neglect case involving your children? If so when and please describe. *
Your answer
Has anybody given you anything or promised you anything in exchange for making certain agreements during mediation? If yes, please describe. *
Your answer
Is there anything else that you would like to share with the mediator? *
Your answer
You must email your responses to your mediator:
Christina Paulson: iowamediationcenter@gmail.com
Heather Burnett: heather@iowamediationcenter.com
A copy of your responses will be emailed to the address you provided.
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