Family Mediation and Divorce Intake Questionnaire

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Please answer all questions to the best of your ability. Questions followed by a red asterisk * MUST be answered in order for this form to be submitted. This application is confidential and will only be viewed by an Intake Specialist.

Date *

YYYY

First Name *

Last Name *

Street Address *

City / State *

Zip *

Home Phone *

Cell Phone *

Email *

Preferred Method of Contact *

Home Phone

Cell Phone

Text

Required

Preferred time of day for Appointment *

Morning

Afternoon

Evening

Gender *

Male

Female

Other

Age *

Race/Ethnicity

Religious Preference

1. Are you employed? *

Yes

What is your job position and work hours?

2. How did you hear about us? If referred by someone, please list their name. *

3. Relationship Status *

Engaged

Married

Seperated

Divorced

Single

4. If Engaged, Married, Separated, or Divorced, please give status and dates of these events:
*

5. Are you remarried? *

Yes

If yes, please list the date of marriage and length of relationship:

6. Number of Children: If none, please put "0" in box and skip to question 18.
*

7. List Children's Name, Age, DOB, and our relationship to the child:

Name of other Parent:

8. List School(s) each child is attending, grade level(s), and note academic or behavioral problems, if any:

9. Living Arrangements: Who is living in the home?

10. Does your child/children live in more than one home?

Yes

Clear selection

If yes, please explain where and with whom they are living with:

11. Do you have concerns about your child/children's emotional well-being and/or physical safety with the other parent?

Yes

Clear selection

If yes, please explain:

12. Has your family ever had any instances or allegations of abuse and/or neglect?

Yes

Clear selection

If yes, please explain:

13. Has an Attorney/Guardian ad Litem been appointed to represent the Children?

Yes

Clear selection

If yes, please give name:

14. Have you ever feared that you would not have access to your children?

Yes

Clear selection

If yes, please explain:

15. Has the other parent ever damaged or destroyed your or your child/children's property or harmed/threatened to harm you or your child/children's pets?

Yes

Clear selection

If yes, please explain:

If no, how could these arrangements be improved?

17. If you are not happy with your current parenting plan, do you feel you are ready to begin working with the other parent on this?

18. Is there a Protective Order in place?
*

Yes

If yes, what was the expiration date?

19. If there are non presently, have there been previous orders of protection?
*

Yes

If yes, what was the expiration date?

20. Has there ever been a physical confrontation?
*

Yes

If yes, please describe frequency and occurrence:

21. Do you have any concerns about your own emotional and/or physical safety with your spouse/partner?
*

Yes

If yes, please explain:

22. Are you in any way intimidated by or fearful of your partner/spouse?
*

Yes

If yes, please explain:

23. Has your spouse/ other parent ever prevented you from having contact with family, friends, or with your children?
*

Yes

If yes, please give details:

24. Do you have concerns regarding the use of alcohol and/or drugs in the family?
*

Yes

If yes, please list concerns:

25. Do you have any fear about answering these questions?
*

Yes

If yes, please explain:

26. Have you or any member of your family recently experienced a traumatic event?
*

Yes

If yes, please explain:

27. Do you feel you were/are an equal partner in the relationship? Could you speak your mind freely, express your point of view and have equal say in the decision-making process with your spouse/partner?
*

28. Is there a history of evaluation, treatment, or hospitalization for psychiatric disorders for either party or the children?
*

Yes

If yes, please describe:

29. Have you or any member of your family ever attempted to significantly hurt yourself/himself/ herself or someone else?
*

Yes

If yes, please briefly give details:

30. If you or a member of your family have previously been in treatment, was a diagnosis given?
*

Yes

If yes, what was the diagnosis?

31. Are you or any member of your family currently in treatment?
*

Yes

If yes, please let us know who is in treatment, the name of the mental health professional that person is seeing and the purpose for seeking treatment:

32. Has any family member ever been on medication for mental health reasons?
*

Yes

If yes, who is taking the medication and what is he/she taking?

33. Have you previously been in a group therapy?
*

Yes

If yes, please describe:

34. Are you or any member of your family currently experiencing any symptoms or have any significant psychosocial or medical issues that are of concern to you?
*

Yes

If yes, please describe:

35. Do you have legal representation?
*

Yes

If Yes, by whom?

36. Have you previously participated in Mediation?
*

Yes

If yes, please list the Mediator's name and dates:

37. If you answered "Yes" to any of the above questions and would like to give more detail or share more information, please do so in the space provided:

38. Please briefly describe the reason you are seeking services. Overall, what would you like to accomplish?
*

In the List of services provided, please check which services are of interest to you:
*

Supervised Visitation

Therapeutic Supervised Visitation

Court-Appointed Parent Coordination

Reunification Therapy

Co-Parent Education/Coaching

Parenting Education

Supervised Child Transfer

Mediation

Adjustment Coaching

Required

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