Example of Mediation Intake Form (for clients)

EXAMPLE Mediation Intake Form (for clients)
Please answer the following questions to help us schedule and prepare for your mediation.

Your information is confidential. We will share it with your attorney if you are represented. We do not share this information with others without your consent.

If you have additional information that you'd like to share or didn't have room for in answering other questions, there is also a general comment box at the end of this form where you can add additional information and clarification.
Name*

First NameMiddle NameLast Name
Have you ever changed your name?*

YesNo
Please list your previous name(s)
Email*
example@example.com
Cell Phone*
Please enter a valid phone number.
Do you have an attorney?*

YesNoNot sure or it's complicated
Please explain (do you have an attorney)
Attorney name

First NameLast Name
Attorney Email
example@example.com
Attorney phone
Please enter a valid phone number.
Do you have a Minnesota court file?

YesNoNot sure or it's complicated
Please explain (do you have a Minnesota court file)
What is the court file number?
What county is the court case located?
We want to make sure that you can actively participate in the mediation session. On a scale of 1-10 below (where 1 is not comfortable at all and 10 is very comfortable), how comfortable are you with participating in mediation with your spouse/partner/ex on the same video meeting?*

1

2

3

4

5

6

7

8

9

10

1 is Not comfortable/ I have big concerns, 10 is Comfortable/ No problem
Do either of you currently have a restraining order (no contact order) against the other person?*

YesNoLet me explain
Please explain (currently have a restraining order question)
Have either of you ever applied for or had a restraining order (no contact order) against the other person?*

YesNoLet me explain
Please explain (applied for or had a restraining order question)
Please upload any restraining (no contact) orders that you have available

Cancelof
Please upload any other documents that you would like to submit related to this mediation

Cancelof
Are there any questions or concerns that you'd like to share with us? (optional)
You are welcome to schedule a brief phone call or Zoom meeting so that we can answer any questions that you might have about the mediation process before the day of the mediation.

Please feel free to click on this phone call scheduling link [insert scheduling link] to schedule a free mediation intake phone call.
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EXAMPLE Mediation Intake Form (for clients)