CLIENT INTAKE QUESTIONNAIRE

CLIENT INTAKE QUESTIONNAIRE
Please fill out this questionnaire as fully and accurately as possible. Your mediator will need this information to be prepared for mediation sessions and to assist you in finalizing the Settlement Agreement. ALL INFORMATION IS CONFIDENTIAL.

This form is designed to alert us to items to which we should give attention. Because we do not know the facts of your case as well as you do, it is hard for us to know ahead of time what issues might suddenly appear in the future. Telling us as much as you know will help us do a better job for you.
Your Full Name*
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Optional
Cell Phone*
Required
Work Phone
Optional
E mail*
example@example.com
Best Method to Contact You?*

Home PhoneCell PhoneWork PhoneEmail
Date of Birth*

MonthDayYear
Current Age*
Current Employer*
Current Occupation
Annual Gross Income
Type of Dispute

DivorceCustody/Parenting PlanFamilyElderHOALandlord-TenantBusinessWorkplaceOther
Do you currently have an attorney?*

YesNo
Attorney Name
Attorney Phone Number
Optional
Attorney Email
example@example.com
Date of Marriage*

MonthDayYear
County and State of Marriage*
Date of Separation*

MonthDayYear
Do you have a desire for reconciliation?
Have you been previously married?

YesNo
If so, how many times?
Previous names (maiden, name change, etc.)
Is there a history of physical abuse?*

YesNo
Are you or the other party currently in the armed forces?

YesNo
Do you have children from this relationship?

YesNo
Do you have a current custody schedule and/or parenting plan in place?

YesNo
Child 1 Name*
Child 1 Birthdate*
Child 1 Age*
Child 1 Grade Level*
How did you choose mediation for resolving this conflict?*
What are your current concerns or issues?*
Are there any areas where you agree or are close to agreement?*
What are the areas of greatest disagreement?*
What are the most important points an agreement must have to satisfy you? Why are they important?
Do you have any suggestions as to what I might do that would help bring about an early resolution?
Are there any special precautions necessary to ensure a safe mediation environment?*
Are there topics or items you are not willing to discuss? Why?
Given that we will be performing this mediation online, are there any issues which I should be aware of that could impact your ability to successfully participate in the mediation?*
What do you like to do in your free time? What hobbies do you have?
How were you referred to JH ADR Services?

Internet Search (Google, Yahoo, Yelp, etc.)Online Platform (Thumbtack, Mediate.com, JWiz, etc.)Flyer or Marketing AdIndividual ReferralOther
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