Family Mediation and Divorce Intake Questionnaire

Family Mediation and Divorce Intake Questionnaire

Please answer all questions to the best of your ability. Questions followed by a red asterisk * MUST be answered in order for this form to be submitted. This application is confidential and will only be viewed by an Intake Specialist.
Date *

Month Day Year
Date
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone *

Area Code Phone Number
Cell Phone *

Area Code Phone Number
E-mail *
Preferred Method of Contact *

Home Phone Cell Phone Email Text
Preferred time of day for Appointment:

Morning Afternoon Evening
Gender *

Male Female
Age *
Date of Birth *

Month Day Year
Date
Race/ Ethnicity
Religious Preference
1. Are you employed? *

No Yes
What is your job position and work hours?
2. How did you hear about us? If referred by someone, please list their name *
3. Relationship Status *

Engaged Married Separated Divorced Single
4. If Engaged, Married, Separated, or Divorced, please give status and dates of these events: *
5. Are you remarried? *

No Yes
If yes, please list the date of marriage and length of relationship:
6. Number of Children: If none, please put "0" in box and skip to question 18. *
7. List Children's Name, Age, DOB, and our Relationship to the child:
EX.) Sally Hanson, 12, 10/09/2007, Step-Mother
Name of other Parent:

First Name Last Name
8. List School(s) each child is attending, grade level(s), and note academic or behavioral problems, if any:
Ex.) Mary, Arden Cahill Elementary, 4th grade, learning disability/No Behavioral Prob
9. Living Arrangements: Who is living in the home?
10. Does your child/children live in more than one home?

No Yes
If yes, please explain where and with whom they are living with:
11. Do you have concerns about your child/children's emotional well-being and/or physical safety with the other parent?

No Yes
If yes, please explain:
12. Has your family ever had any instances or allegations of abuse and/or neglect?

No Yes
If yes, please explain:
13. Has an attorney/Gaurdian ad Litem been appointed to represent the Children?

No Yes
If yes, please give name:
14. Have you ever feared that you would not have access to your children?

No Yes
If yes, please explain:
15. Has the other parent ever damaged or destroyed your or your children's property or harmed/threatened to harm you or your children's pets?

No Yes
If yes, please explain:
16. Are you happy with your current parenting arrangements?

No Yes
If no, how could these arrangements by improved?
17. If you are not happy with your current parenting plan, do you feel you are ready to begin working with the other parent on this?
18. Is there a Protective Order in place? *

No Yes
If yes, please explain and include the protective order's expiration date:
19. If there are none presently, have there been previous orders of protection? *

No Yes
If yes, what was the expiration date?
20. Has there ever been a physical confrontation between you and the other parent? *

No Yes
If yes, please describe frequency and occurrence:
21. Do you have any concerns about your own emotional and/or physical safety with your spouse/partner? *

No Yes
If yes, please explain:
22. Are you in any way intimidated by or fearful of your partner/spouse? *

No Yes
If yes, please explain:
23. Has your spouse/ other parent ever prevented you from having contact with family, friends, or with your children? *

No Yes
If yes, please give details:
24. Do you have concerns regarding the use of alcohol and/or drugs in the family? *

No Yes
If yes, please list concerns:
25. Do you have any fear about answering these questions? *

No Yes
If yes, please explain:
26. Have you or any member of your family recently experienced a traumatic event? *

No Yes
If yes, please explain:
27. Do you feel you were/are an equal partner in the relationship? Could you speak your mind freely, express your point of view and have equal say in the decision-making process with your spouse/partner? *
28. Is there a history of evaluation, treatment or hospitalization for psychiatric disorders for either party or the children? *

No Yes
If yes, please describe:
29. Have you or any member of your family ever attempted to significantly hurt yourself/ himself/ herself or someone else? *

No Yes
If yes, please briefly give details:
30. If you or a member of your family have previously been in treatment, was a diagnosis given? *

No Yes
If yes, what was the diagnosis?
31. Are you or any member of your family currently in treatment? *

No Yes
If yes, please let us know who is in treatment, the name of the mental health professional that person is seeing and the purpose for seeking treatment:
32. Has any family member ever been on medication for mental health reasons? *

No Yes
If yes, who is taking the medication and what is he/she taking?
33. Have you previously been in group therapy? *

No Yes
If yes, please describe:
34. Are you or any member of your family currently experiencing any symptoms or having any significant psychosocial or medical issues that are of concern to you? *

No Yes
If yes, please describe:
35. Do you have legal representation? *

No Yes
If so by whom?
36. Have you previously participated in Mediation? *

No Yes
If yes, please list the Mediator's name and dates:
37. If you answered "Yes" to any of the above questions and would like to give more detail or share more information, please do so in the space provided:
38. Please briefly describe the reason you are seeking services. Overall, what would you like to accomplish? *
In the List of services provided, please check which services are of interest to you: *

Initial Assessment and Consultation Comprehensive Assessment Mediation Counseling Co-Parenting Education Co-Parenting Coaching Supervised Visitation Therapeutic Supervised Visitation Supervised Child Transfer Collaborative Legal Consultation Court-appointed Parent Coordination Reunification Therapy Parenting Plan Development Court Testimony
PLEASE SUBMIT ALL COURT DOCUMENTS. IF YOU DON'T HAVE THEM YET, YOU CAN EMAIL THEM TO OUR RECEPTIONIST, ASHLEY, AT ASHLEY@FAMILYCAREGNO.COM.

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