The Mediation Centre

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.

Today's Date:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year20102011201220132014

Referred by:

Lawyer

Self

Other

If other, please specify:

General Information

Full Name: *

Age: *

Present Address: *

City and Postal Code: *

Primary Phone: *

Cell Phone:

Email Address:

Employer

Employer's Name:

Telephone:

Okay to call at work?:

Yes

No

Lawyer

Name of Retained Lawyer:

Telephone:

Name of Lawyer(s) Consulted: *

Name of the person who you would like to settle issues with: *

Are there any legal reasons that will prevent you from communicating directly or indirectly with this person?: *

Yes

No

If so, please explain.:

Information for Mediator

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

Did you and the person of this dispute ever live together?: *

Yes

No

When did you begin living common-law?:

(Year)

What was your date of marriage?:

(Month/Year)

When did you last separate?: *

(Month/Year)

If your separation is recent, do you have any interest in reconciliation with this person?: *

Yes

No

Please provide a brief history of your marriage/relationship: *

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

Please tell us one positive thing about the opposing person: *

Are there children from this marriage/relationship?: *

Yes

No

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

Children

First Child's Name:

First Child's Date of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year19821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

First Child is living with:

Second Child's Name:

Second Child's Date of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year19821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

Second Child is living with:

Third Child's Name:

Third Child's Date of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

Third Child is living with:

Fourth Child's Name:

Fourth Child's Date of Birth:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013

Fourth Child is living with:

Are you currently in a new marriage/common-law relationship?: *

Yes

No

Is so, since when?:

Name of current partner:

Do you have other children not mentioned above that are still dependents?:

Yes

No

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

Other Children

Children's Name:

Their Age:

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.

First Issue: *

Why is this a concern to you?: *

Second Issue:

Why is this a concern to you?:

Third Issue:

Why is this a concern for you?:

Fourth Issue:

Why is this a concern for you?:

Have you started legal action in court?: *

Yes

No

If yes, where are you at?:

Prior to first court date

First appearance court

Case conference date

Settlement conference

Other

Next Court Day:

MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day12345678910111213141516171819202122232425262728293031

Year20102011201220132014

Agreement to Mediate

Information is confidential: *

I understand that information provided to The Mediation Centre is confidential and may not be used at court. I agree that no person involved with The Mediation Centre shall be a compellable witness in any current or future legal proceedings in regards to this file.

Process is voluntary: *

I understand that mediation is a voluntary process and that the mediator is a neutral person who is present to help us come to an agreement that is acceptable to all of us. The mediator will not provide legal advice to any of the parties.

Fees: *

I also understand that there is a fee for mediation. Subsidized Mediation is based on my annual income (including spousal support) and number of dependants. (example: $20,000 would be $10/hr - $50,000 would be $75/hr) This fee will be provided to me prior to my individual interview and will be payable before mediation proceeds. Private Mediation allows us to select the mediator of our choice. I have seen the mediator’s private rate on their profile – we have agreed to_____________________________.

Mediation Questionnaire

What is the highest level of education you have completed?: *

High school

Some post-secondary schooling

College/technical degree

University degree, undergraduate

Other

If other, please specify:

Where does your annual gross income fall?: * - Select -$10-20,000$20-30,000$30-40,000$40-50,000$50-60,000$60-70,000$70-80,000$80-90,000$90-100,000$100-110,000$110-120,000$120,000 or more

What is your first language?:

Do you speak another language?:

Do you have certain disabilities you would like us to be aware of?:

Yes

No

If so, please specify:

Who made the decision to separate/end the relationship?: *

Me

Partner

Both

If you lived together - out of the following choices, which best suit your reasons for separating?

Primary Reason: * - Select -My physical abuse against partnerPartner's physical abuse against meMy emotional abuse towards partnerPartner's emotional abuseMy drug/alcohol problemPartner's drug/alcohol problemPoor communication on my partPartner's poor communicationMy sexual problemsPartner's sexual problemsI took advantage of my partnerPartner took advantage of meMy mental healthPartner's mental healthMy adulteryPartner's adulteryGreat deal of conflict

Secondary Reason: - None -My physical abuse against partnerPartner's physical abuse against meMy emotional abuse towards partnerPartner's emotional abuseMy drug/alcohol problemPartner's drug/alcohol problemPoor communication on my partPartner's poor communicationMy sexual problemsPartner's sexual problemsI took advantage of my partnerPartner took advantage of meMy mental healthPartner's mental healthMy adulteryPartner's adulteryGreat deal of conflict

Additional Reason: - None -My physical abuse against partnerPartner's physical abuse against meMy emotional abuse towards partnerPartner's emotional abuseMy drug/alcohol problemPartner's drug/alcohol problemPoor communication on my partPartner's poor communicationMy sexual problemsPartner's sexual problemsI took advantage of my partnerPartner took advantage of meMy mental healthPartner's mental healthMy adulteryPartner's adulteryGreat deal of conflict

Other Reason:

CAPTCHA

Please type what you see to proceed. This helps us to prevent automated spam submissions.

What code is in the image?: *

Enter the characters shown in the image.