Mediation Intake Form

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 NameLast Name
Date:

MonthDayYear
Date
Referred By:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:

Area CodePhone Number
Cell Phone:
Work Phone:
Email:
example@example.com
Is your matter currently in court ?
What is the status of the court matter ?
Employer / Job:
Annual Income:
What is your first language ?
Date of Marriage (if applicable):

MonthDayYear
Date
Date of Cohabitation:

MonthDayYear
(if applicable)
Date of Separation:

MonthDayYear
(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:

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 ?
Should be Empty:

AP MEDIATION INTAKE FORM