AP MEDIATION INTAKE FORM
This document is strictly confidential, and is provided to us as part of a confidential (closed) mediation process. The only exceptions are if a child is at risk of harm, any person is in imminent danger, or a judge orders disclosure of this information.
Name:
*
First Name
Last Name
Date:
*
-
Month
-
Day
Year
Date
Referred By:
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
-
Area Code
Phone Number
Cell Phone:
Work Phone:
Email:
*
example@example.com
Is your matter currently in court ?
*
Yes
No
What is the status of the court matter ?
Employer / Job:
*
Annual Income:
*
What is your first language ?
*
Date of Marriage (if applicable):
-
Month
-
Day
Year
Date
Date of Cohabitation:
-
Month
-
Day
Year
(if applicable)
Date of Separation:
-
Month
-
Day
Year
(if applicable)
Your Lawyer's name:
Other Party's Name:
*
Other's Party Employer / Job / Annual Income:
*
Are there any legal reasons that prevent you from communicating directly or indirectly (restraining order / peace bond):
*
Who made the decision to end the relationship?
*
Tell us one (or more) positive things about the other party:
Please provide a brief history of your marriage/relationship:
*
Are there children of this marriage/relationship?
*
( Childs Name , Age , Who is the child living with )
What are the issues that you want to discuss in mediation and why are these issues important to you?
*
(Please explain)
Do you have any concerns about being in the same room with your former partner?
*
(Please explain)
What do you consider to be the greatest obstacle in reaching an agreement in mediation?
*
(Please explain)
Indicate the reasons that best explain your reasons for separating:
*
Physical abuse/violence
Threats
Drug/alcohol abuse
Mental illness
Infidelity
Poor communication
Emotional abuse
Incompatibility
Great deal of conflict
Taking advantage of the other persons
Other
Is there any: (a)Police File:
(b)CAS File:
Do you have any disabilities you would like us to know about ?
Is there anything else you want us to know ?
Submit
Should be Empty: