Form

MEDIATION INTAKE FORM
CROWE LAW OFFICE FAMILY LAW & MEDIATION This intake form is strictly confidential and is provided to us as part of a confidential (closed) mediation process. We will not share any of this information without your consent. IMPORTANT: Each party is required to fill out and submit their own intake form. Intake forms are needed from both parties to proceed with mediation. NOTE: It will take you approximately 15 minutes to fill out this intake form. Thank you for taking the time to answer these questions in advance of scheduling your individual intake meeting. During your individual intake meeting, you will meet alone with the mediator (in-person or online via Zoom), and the mediator will assess if mediation is appropriate and, if so, how to design the mediation process.
SECTION 1: Contact Information
Today's Date*
Referred by: (If not referred by anyone put "Self")*
Your Full Name*

First NameLast Name
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email: Non-confidential email address that can be shared with the other party*
example@example.com
Other Party's Name *

First NameLast Name
Other's Party's Email
example@example.com
Other Party's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
We ask for the other party's contact information so we can contact the other party to let them know you have submitted your intake form, because we require an intake form from both parties. If you do not provide us with their contact information we will not contact them.
Your Lawyer's Name (if any)

First NameLast Name
Your Lawyer's Email
example@example.com
Your Lawyer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Your first language
We provide services in English. Limited services provided in French and in Spanish. If you speak another language and require interpretation, please make arrangements for a person 19 years of age or older to attend your intake meeting to interpret. Children of the relationship should not interpret for either parent without the consent of both parents.
Do you wish to self-identify as Indigenous (First Nation, Métis, Inuit)?

YesNo
Do you have any disabilities you would like us to know about?

Yesno
If yes, please let us know how we can support you
SECTION 2: Employment & Income
Please indicate all the sources of income that you have: (check ALL that apply)
Please indicate all the sources of income that you have: (check ALL that apply)

Employment (T4)Self-employmentUnemployment insurance (EI)Social assistance (OW, ODSP)PensionSupport from family membersSpousal supportRental incomeOther
Please collect documents showing your income and have them ready to show your mediator at your individual intake meeting.
What is your total gross annual income (before taxes) from all sources?*
Name of your employer, business or company*
Your role/job title*
SECTION 3: Children’s Information If this does not apply, please write N/A
Are there any children's issues in this mediation?*

YesNo
Children subject to this mediation: Child 1

First NameLast Name
Date of Birth
Child 2

First NameLast Name
Date of birth
Child 3

First NameLast Name
Date of birth
Child 4

First NameLast Name
Date of birth
Has Children's Aid Society been involved with your family?

YesNo
Has the Office of the Children's Lawyer been involved with your family?

YesNo
Has a Voice of the Child Report been done?

YesNo
SECTION 4: Relationship History
Date of cohabitation Please put N/A if Not Applicable*
Date of marriage Please put N/A if Not Applicable*
Date of separation Please put N/A if Not Applicable*
Date of divorce Please put N/A if Not Applicable*
Do you have a separation agreement?*

YesNo
Is there a No Contact Order/Protection Order in place? e.g. bail order, probation order, peace bond, restraining order*

YesNo
Are you comfortable to meet in the same room with the other person?*

YesNo
Are you able to talk about the things that are important to you with the other person?*

YesNo
Do you have any concerns for the safety of the children?*

YesNo
Do you have any concerns about the other person's alcohol or drug use?*

YesNo
Do you have any concerns about the other person's mental health?*

YesNo
Do you have any concerns for your safety?*

YesNo
Do you have any other concerns that you want to discuss with the mediator?*

YesNo
Indicate all the reasons that best explain why you separated (check all that apply)*

ThreatsInfidelityConflicts about moneyConflict about petsPoor communicationEmotional abuseIncompatibilityGreat deal of conflictTaking advantage of the other personOther
SECTION 5: Issues for Mediation
Indicate the issues for mediation*

CommunicationImportant decisions about the childrenDaily/weekend/holiday schedule for the childrenFuture child supportChild support arrearsChanging child supportSpousal supportChildren's activitiesPaying for children's activitiesFinancial disclosureIncome determinationTransportation for the childrenTravel & children's government documentsChange of residenceRelocationDivision of propertyNew partnersOther
Please list the three most important or time sensitive issues you wish to mediate*
Is there anything else you want us to know?*
SECTION 6: Privacy and Technology
Do you have your own computer that is private, password-protected, has a camera and a microphone?*

YesNo
Do you have your own cellphone that is private, password-protected, has a camera and a microphone?*

YesNo
Do you have a private place where you can have an online meeting without anyone else hearing or watching you (including children)?*

YesNo
Are you living in the same residence as the other person?*

YesNo
I consent to an email being sent to the other party, advising that I have submitted my intake form*

YesNo
I understand that before mediation can take place, both parties will need to sign an Agreement to Mediate (in addition to each party submitting this intake form)*

YesNo
Should be Empty:

MEDIATION INTAKE FORM

SECTION 1: Contact Information

We ask for the other party's contact information so we can contact the other party to let them know you have submitted your intake form, because we require an intake form from both parties. If you do not provide us with their contact information we will not contact them.

SECTION 2: Employment & Income

Please indicate all the sources of income that you have: (check ALL that apply)

Please collect documents showing your income and have them ready to show your mediator at your individual intake meeting.

SECTION 3: Children’s Information If this does not apply, please write N/A

SECTION 4: Relationship History

SECTION 5: Issues for Mediation

SECTION 6: Privacy and Technology