New Client Intake Form

New Client Intake Form

This document is strictly confidential. It is designed to assist us in preparing for your first, one-on-one meeting, and will only be seen by our office personnel.
Name*

First NameLast Name
Pronouns (optional)
What service are you seeking?*
Address*

Street Address

Street Address Line 2

CityProvince

Postal Code
Phone Number*
Ok to text?*
E-mail*
example@example.com
Permission to display your email address in group emails with the other party/ lawyer?*
Do you identify as First Nations, Inuit, or Métis?
If yes, please provide more details (e.g. First Nation Band).
Is there anything you would like us to know with respect to your race, culture, or heritage?
Do you have any special needs/ disabilities/ diagnoses that you would like us to know?
Is there anything you would like us to know with respect to your identity or gender?
Lawyer's Name

First NameLast Name
Lawyer's Phone Number
Please enter a valid phone number.
Lawyer's Email
example@example.com
Permission to contact your lawyer?*
Name of the Other Party.*

First NameLast Name
Date of marriage/ cohabitation.

MonthDayYear
Date
Date of separation.

MonthDayYear
Date
Do you have an interest in reconciliation with this person?*
Who made the decision to end the relationship?*
Indicate which reason(s) for separation best relate to your situation.*

Addiction(s)Drug/ Alcohol UseFamily ConflictIncompatibilityInfidelityMental IllnessPoor CommunicationSexual ProblemsOther
Are there any legal reasons that prevent you from communicating directly or indirectly with the other party (e.g. restraining order, peace bond, bail conditions)?*
If yes, please provide a copy of the conditions (e.g. restraining order, peace bond, bail conditions).

Cancelof
Is this matter in court?*
Are there children from this relationship? If yes, please share their name(s) & age(s) below.*
Number
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Are you in a new relationship?*
If yes, have the children met this person?
If yes, do you live with this person?
Do you have children from other relationships?
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Child's First Name Last Name Age
Do any of your children have special needs?
If yes, please provide more details.
Is the children's aid society currently involved with your family?*
If yes, please provide the worker's name and contact information.
Has the children's aid society ever been involved with your family?*
Tell us at least one (1) positive thing about the other person.*
What are the issues you wish to discuss?*
What do you consider to be the greatest obstacle to reaching an agreement?*
Is there anything else you would like to share?
Confidentiality Agreement:

The Mediator/ Collaborative Family Neutral (CFN)/ Voice of the Child Report Practitioner (VCRP) will not voluntarily disclose any verbal and/ or written communication that takes place during the intake appointment(s). The following exceptions apply:

a) Where information suggests an actual or perceived threat to human life and/ or safety (notify CAS for a child, notify Police for an adult);

b) Where ordered to do so by law;

c) Disclosure for my lawyer or third party advisors;

d) Where any party makes a claim or complaint against the Mediator, their staff or interns;

e) Research and/ or educational purposes (non-identifying information);

f) On written consent.

I consent to the presence of language interpreters, interns and/ or assistants for the purposes of professional training. All such observers and/ or participants are also bound by the same rules of confidentiality as the Mediator/ CFN/ VCRP as outlined in the previous paragraph.

Mediation, Collaborative and Voice of the Child Reports are voluntary processes, and any participant has the right to withdraw from the process at any time. The Mediator/ CFN/ VCRP will not disclose if a party withdraws from the process unless the party consents to the disclosure.

I shall not record the content of any mediation/ collaborative/ voice of the child report appointments through any means such as audio, video etc.

I shall not summons nor otherwise require the Mediator/ CFN/ VCRP to testify and/or produce records and/ or notes in any current or future civil proceedings (including Family Court and Child Welfare Court).

It is the discretion of the Mediator/ CFN as to whether or not they meet with the child(ren) as part of this process. The / CFN/ VCRP meeting with the child(ren) does not guarantee that the mediation/ collabrative process will continue to the joint mediation session.
I acknowledge the Confidentiality Agreement.*
Cancellation Policy:

In the event that the client misses a scheduled appointment or cancels with less than twenty-four (24) hours notice, the client shall be responsible for full payment of the missed/ cancelled appointment. The fee for intake appointments is $150.

All outstanding fees must be paid in full prior to rescheduling appointments.
I acknowledge the Cancellation Agreement.*
Consent and Waiver for the use of Artifical Intelligence in Note-Taking:

As part of providing Collaborative/ Mediation/ VCR services, Paul Brown Mediation may use an artificial intelligence (AI) tool to assist with note-taking and documentation. The AI platform used is compliant with PHIPA (Personal Health Information Protection Act), PIPEDA (Personal Information Protection and Electronic Documents Act), and HIPAA (Health Insurance Portability and Accountability Act) standards for privacy and security.

The AI tool functions only as an administrative support for creating and organizing notes. All information processed is protected with encryption and stored in compliance with applicable privacy legislation. At no time will the AI tool make clinical decisions, provide treatment, or replace my professional judgment. You retain the right to request that AI not be used in the documentation of your sessions. While all reasonable safeguards are taken, you acknowledge and accept that no system can guarantee absolute protection of personal health information.
I acknowledge the Consent and Waiver for the use of Artifical Intelligence in Note-Taking.*
I certify that the above information is correct to the best of my knowledge.*

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I acknowledge the Cancellation Policy.*
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