Family Mediation Intake Form

Please take a few moments to answer this questionnaire. This document is strictly confidential and will be seen only by our office personnel.  Please mark clearly any information, which you are uncomfortable discussing with the other party in mediation.

General Information
Employer
Lawyer
Information for Mediator

This information is confidential; completing it will help us assign a mediator best suited to your needs.

(Year)

(Month/Year)

(Month/Year)

You will discuss individually with mediator so just point form: significant events such as children, reason for separation – short, quick summary for discussion later

If you answer "yes", please provide each child's information below.

Children

If you answer "yes", please provide each child's information below.

Other Children
Please briefly provide us with what you believe are the issues for this mediation

Issues will be discussed and expanded in your individual meeting with the mediator.

Agreement to Mediate
Mediation Questionnaire
If you lived together - out of the following choices, which best suit your reasons for separating?
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