Your Details:
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Occupation
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
Referred from?
*
Please Select
Internet
Another client
Solicitor (Please specify...)
Other (Please specify...)
Solicitor Name/Other
*
Please select which of our services you are interested in (can select multiple if applicable)
Family Dispute Resolution / Mediation
Child Consultation
Post-Separation Child Therapy
Post-Separation Adult Therapy
Post-Separation Family Therapy
Do you consent to us contacting the other party to notify them that you have initiated the Family Dispute Resolution/mediation process and/or would like to proceed with Child Consultation, Child Therapy and/or Family therapy? (The other party will NOT be contacted if you are registering solely for Post-Sepration Therapy for yourself)
*
Yes
No
Do you have any safety concerns if we contact the other party for the above purpose/s?
*
Yes
No
N/A
If yes, please specify
*
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If interested in our mediation service, what issues do you wish to discuss in Family Dispute Resolution/Mediation
*
Parenting/children's matters
Financial/property settlement
Both of the above
The Other Party's/Parent's Details:
Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Occupation
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
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Next
Your Child/ren's Details:
If applicable
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Back
Submit
Next
Are there any AVOs/ADVOs?
*
Yes
No
If yes, please upload a copy
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Are there any Family Court Orders
*
Yes
No
If yes, please upload a copy
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Do you have any safety concerns for yourself/your family?
*
Yes
No
If Yes, please specify
Should be Empty: