Aligned Choices - Family Mediation Intake Form
This document is strictly confidential and is provided as part of a closed mediation process. The only exceptions to this are if a child is at risk of harm, if any person is in imminent danger, or in the event a judge orders disclosure of this information. Please answer this questionnaire as completely as possible. The information you provide will assist me in determining the process that will best facilitate the discussions to take place between us.
Email address *
Name: *
Address: *
Telephone *
Email *
Can this email/contact info address be shared with the other party? *
Employer/Job *
Annual Income *
Date of Marriage/Cohabitation *
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/
DD
/
YYYY
Date of Separation *
MM
/
DD
/
YYYY
Name of Family Lawyer
Have any proceeding commenced in court? *
Name of the other party *
Age of the other party *
His/Her employer or job
Do you have any interest in reconciling with this person? *
Who made the decision to end the relationship? *
Are there any legal reason(s) preventing you from communicating directly with the other party (restraining order/peace bond)? *
Please tell me one positive thing about the other party? *
Please provide a brief history of your marriage/relationship? *
Are there any children of the marriage/relationship? *
Please provide name/age/where the child is currently residing?
What issues are you looking to discuss in mediation? *
For each issue, please write down why it is important to you? *
Do you have any concerns about being in the same room as the other party? *
If answer to previous question is 'yes', please describe why? *
What do you consider to be the greatest obstacle to reaching agreement in mediation? *
Indicate the factors that best explain your reasons for separating
Check all that apply
Physical Abuse/Violence
Emotional Abuse
Drug/Alcohol use
Mental Illness
Infidelity
Poor Communication
Threats
Incompatibility
Great deal of conflict
Taking advantage of the other person
Are there any other reasons for the separation?
Do you have any disabilities you would like me to know about?
Is there anything else you would like me to know?
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