Mediation Intake Form

Employment Information
Name of Employer
Job Title
How long at this job
Income: upload a scan or photo of your most recent paystub with Year-to-Date or last year's W-2/1099

If you don't have access to your documents right now, that can be submitted later
Cancelof
Describe your typical weekly work schedule
Nature of Disability
Type and year of last job
Monthly income amount
Business Name
Co-owners (if any)
How long in business
Additional notes regarding income (if any):
Who provides your medical insurance
Self, spouse, medicaid, medicare
Who provides the children's medical insurance
Self, other parent, medicaid
Cost of children's insurance premium

Relationship Information
Location of Marriage
County/City and State
Date of Marriage
Date of Separation
Additional notes regarding the circumstances of the separation (if any)
Briefly describe any PRESENT or PAST court cases involving both of you (if any)
Protective Order, Assault & Battery, Custody, etc.

Children's Information
Child's Name & Birthdate
Other children in the home
Example: You have custody of a niece/nephew/cousin, etc.
Special considerations for any of the children (if any)
Briefly describe any PRESENT or PAST Child Protective Services case or investigation involving either of you (if any)

Marital Assets

Things that may need to be divided as part of separation/divorce
Joint bank accounts (owned as of separation date) with estimate of current balance
Separate bank accounts (owned as of separation date) with estimate of current balance
Your vehicle
Other vehicles, titled in one or both names:
Year, Make & Model / How titled / Debt (if any)
Your Retirement accounts (type [e.g. IRA, 401k, VRS] and estimated balance)
Other personal property that may need to be addressed:
Furniture, Recreational Vehicles, Trailers, 4-wheelers, etc.
Marital home is:
Marital home
Additional real estate (if any)
Additional real estate notes

Marital Debts

Things that may need to be divided as part of separation/divorce - including credit cards, student loans, medical bills, personal loans, etc.
Joint debt (owed as of separation date) with estimate of current balance & monthly payment
Your separate debt (owed as of separation date) with estimate of current balance & monthly payment

Description of the issues

Briefly summarize what you hope to address in mediation

By my electronic signature below, I agree to the following:

I have provided information in this form to the best of my current knowledge.

I will update this information if anything changes.

I understand that even though the mediator is a licensed attorney, she is not acting as my attorney in this situation, and submitting this form does not create attorney-client privilege.

I understand that the information I am providing is confidential, and will only be shared within the mediation process.
Signature

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Mediation Client Information