Ames Mediation Intake Form

Ames Mediation Intake Form

Complete this form to initiate mediation services and acknowledge the terms and scope of the process.
Party 1 Intake
Spouse/Party 1 Full Legal Name

First NameMiddle NameLast Name
Spouse/Party 1 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse/Party 1 Email
example@example.com
Spouse/Party 1 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Party 1 Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Spouse/Party 1 State of Residence
Party 2 Intake
Spouse/Party 2 Full Legal Name

First NameMiddle NameLast Name
Spouse/Party 2 Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse/Party 2 Email
example@example.com
Spouse/Party 2 Phone
Please enter a valid phone number.Format: (000) 000-0000.
Spouse/Party 2 Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Spouse/Party 2 State of Residence
Matter Details
Marriage Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
County and State of Marriage

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
County and State Where Matter May Be Filed

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Minor Children
Issues to Mediate

Other
If Other, Please Explain
Payment Acknowledgment
Payment acknowledgment
Acknowledgment
Required Acknowledgments and Signatures
Required Confirmations
Spouse/Party 1 Electronic Signature
Spouse/Party 1 Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Spouse/Party 2 Electronic Signature
Spouse/Party 2 Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Patricia A. Ames Electronic Signature
Should be Empty:

Ames Mediation Intake Form

Party 1 Intake

Party 2 Intake

Matter Details

Payment Acknowledgment

Required Acknowledgments and Signatures