Aligned Choices - Family Mediation Intake Form

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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 *

Name: *

Address: *

Telephone *

Can this email/contact info address be shared with the other party? *

yes

Employer/Job *

Annual Income *

Date of Marriage/Cohabitation *

YYYY

Date of Separation *

YYYY

Name of Family Lawyer

Have any proceeding commenced in court? *

yes

Other:

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? *

yes

Other:

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)? *

Yes

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? *

yes

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? *

yes

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?

Submit

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