Separation/Divorce Mediation Step 1 of 5 20% 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 MM slash DD slash YYYY Please help us understand what type of family mediation you need assistance with.* On-Site Court Mediation - You have a pending court date, so someone (court staff, judge, lawyer) recommended mediation in regard to all issues related to your children. Off-Site - You are not in court, you have issues to resolve for your children, spousal support and/or property/financial issues. Referred By Judge Lawyer Self Court staff Other General InformationName* First Last Date of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What contact number can you be reached at during the day?*Email* Employer* LawyerIf you have of Retained Lawyer please provide name* Name of any Lawyer(s) Consulted - or Legal Aid*(we need this for possible lawyer/mediator conflicts) 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? 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? date or n/aWhat was your date of marriage? date or n/aWhen did you last separate?* date or n/aIf your separation is recent, do you have any interest in reconciliation with this person?* Yes No Do you both still reside in the same home?* 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 Child 1 Name First Age and who do they live with? Child 2 Name First Age and who do they live with? Child 3 Name First Age and who do they live with? Child 4 Name First Age and who do they live with? Are you currently in a new marriage/common-law relationship?* Yes No If so, since when? MM slash DD slash YYYY Name of current partner First Last Do you have other children not mentioned above that are still dependents? Yes No Child 1 Name First Child 1 is living with Child 2 Name First Child 2 is living with Child 3 Name First Child 3 is living with What are the issues to be mediated?* Parenting and child support Spousal Support Selling your home Pension and financial other Please briefly provide us in point form -- with what you believe are the concerns for this mediation?*(Issues will be discussed and expanded in your individual meeting with the mediator)Have you started legal action in court?* Yes No If yes, where are you atPrior to first court date MM slash DD slash YYYY First appearance court Case conference date MM slash DD slash YYYY Settlement conference Other Next court day MM slash DD slash YYYY Do you have have a place where you can have a private on-line meeting with us? Yes No Agreement to Mediate I understand that information provided to The Mediation Centre (by me or any other party in connection with this proposed mediation) 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. I understand that mediation is a voluntary process and that the mediator is a neutral facilitator who is present to help the parties come to an agreement that is acceptable to them. The mediator will not provide legal advice to either of the parties. I also understand that there may be a fee for mediation. This depends on whether I meet the standard for on-site court mediation or qualify for a subsidized program (which is based on my annual total income and number of dependents). This fee will be calculated prior to my individual meeting (no charge for this) and will be payable before the joint mediation session proceeds. * I Agree to the above. I understand that you are a training centre and from time to time interns will sit in on mediations. I will be asked for permission prior to the mediation. Mediation QuestionnaireWhat is the highest level of education you have completed?* high school or less some post-secondary schooling college/technical degree university degree, undergraduate other Where does your GROSS annual income fall? (this must includes salaries, spousal support, rental income, social assistance, commission, bonuses, pensions, disability benefits, income from business)* $10-20,000 $20-30,000 $30-40,000 $40-50,000 $50-70,000 $70-90,000 $90-110,000 $110-130,000 $130,000-150,000 $150,000-170,000 $170,000-200,000 $200,000 or more What is your first language? Do you speak and understand a second language?* English French Other Do you have certain disabilities you would like us to be aware of in regards to Mediation?*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.* my physical abuse against partner partner’s physical abuse against me my emotional abuse towards partner partner’s emotional abuse my drug/alcohol problem partner’s drug/alcohol problem poor communication on my part partner’s poor communication my sexual problems partner’s sexual problems I took advantage of my partner partner took advantage of me my mental health partner’s mental health my adultery partner’s adultery great deal of conflict other (select three) CAPTCHA FormsAgreement to Meet Via Technology Separation/Divorce Mediation Intake Family Arbitration Inquiries Family Coach Inquiries Workplace Inquires Family Conflict Inquiries
