Client Intake Form: Mediation

Client Mediation Intake Form

Information provided on this form will be forwarded to your mediator
Today's Date:*

MonthDayYear
Date

About You
Full Name (including aliases, all previous names): *
Your Email Address(es): *
example@example.com - you may list more than one email address above
Telephone Number (Cell): *
Please enter a valid phone number.
Address (please provide your home and work address): *
Name of Your Employer:*
Your Occupation:*
Your Annual Income: *
Telephone Number (Work):
Please enter a valid phone number.
Your Date of Birth: *

MonthDayYear
Date
Your Place of Birth: *
Do you have a disability or a medical condition?*

YesNo
If yes, please specify:
What is your first language? *
example: English
Is there a court proceeding between you and your spouse?*

YesNo
Have you been to court on this file?*

YesNo
If yes, what were the issues in dispute and was a Court Order entered?
Upload any orders in place affecting the children:

Cancelof
Do you have a lawyer?*

YesNo
If yes, please provide their name and telephone number:
example: Mary Smith, 604-231-1111

About Your Spouse
Your Spouse's Full Name: *
Your Spouse's Date of Birth: *

MonthDayYear
Date
Your Spouse's Place of Birth (City, Prov, Country): *
example: Vancouver, BC, Canada
Name of their Employer: *
Occupation:
What is his/her annual income?*
Does he/she have a disability or a medical condition?*

YesNo
If yes, please specify:
Does he/she have a lawyer?*

YesNo
If yes, please provide their name and telephone number:
example: Mary Smith, 604-213-1111

What is the current parenting time schedule?
Is one party paying support to the other for the children? If so, please provide details:
Are there children from any other marriage/relationship?*

YesNo

Safety / Conflict
Are you comfortable being alone with your spouse and discussing difficult issues?*

YesNo
If no, please rate your comfort level from 1 to 10 below (1 = comfortable, 10 = extremely uncomfortable):
Has there been any violence in your relationship?*

YesNo
If yes, please describe (including when, what, where and who):

If you answered "YES" in the table above, please describe (including when, what, where and who):
How would your spouse describe the events described above?
Have the police ever been called?*

YesNo
If yes, was anyone charged?

YesNo

Are there any weapons in the home?*

YesNo
If yes, please describe:
How would you describe the method of communication between you and your spouse? (Check all that apply):*

In PersonEmailTextPhonecallsOther
How would you describe the quality of communication between you and your spouse?*

GoodBad
If bad, please describe:
If good, please describe:
Do you or your spouse have a drug or alcohol problem?*

YesNo
If yes, please describe:
Are you concerned about other people significantly influencing you or your spouse in negotiations?*

YesNo
If yes, please describe:

Mediation Issues
What do you believe is the greatest obstacle to reaching an agreement in mediation? *
Do you have any concerns you would like to discuss with the mediator?*

YesNo
If yes, please specify:
This form is private and confidential, provided as part of a screening process within a family mediation process. We will not share any of this information without your consent. The only exception to the confidentiality is if the information reveals that the safety of a child is at risk or that there are threats of imminent harm to yourself or another person.
Your Signature:

Clear
Should be Empty:

	Yes	No
Conviction
Guilty Plea
Peace Bond / Restraining Order

Client Mediation Intake Form