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.
* Required
Email address
*
Your email
Name:
*
Your answer
Address:
*
Your answer
Telephone
*
Your answer
Email
*
Your answer
Can this email/contact info address be shared with the other party?
*
yes
No
Employer/Job
*
Your answer
Annual Income
*
Your answer
Date of Marriage/Cohabitation
*
MM
/
DD
/
YYYY
Date of Separation
*
MM
/
DD
/
YYYY
Name of Family Lawyer
Your answer
Have any proceeding commenced in court?
*
yes
No
Other:
Name of the other party
*
Your answer
Age of the other party
*
Your answer
His/Her employer or job
Your answer
Do you have any interest in reconciling with this person?
*
yes
No
Other:
Who made the decision to end the relationship?
*
Your answer
Are there any legal reason(s) preventing you from communicating directly with the other party (restraining order/peace bond)?
*
Yes
No
Please tell me one positive thing about the other party?
*
Your answer
Please provide a brief history of your marriage/relationship?
*
Your answer
Are there any children of the marriage/relationship?
*
yes
No
Please provide name/age/where the child is currently residing?
Your answer
What issues are you looking to discuss in mediation?
*
Your answer
For each issue, please write down why it is important to you?
*
Your answer
Do you have any concerns about being in the same room as the other party?
*
yes
No
If answer to previous question is 'yes', please describe why?
*
Your answer
What do you consider to be the greatest obstacle to reaching agreement in mediation?
*
Your answer
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
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?
Your answer
Do you have any disabilities you would like me to know about?
Your answer
Is there anything else you would like me to know?
Your answer
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