Mediation Client Intake Form 3

Mediation Client Intake Form 3
Please fill out fields carefully and click submit.
Full Name
First NameMiddle NameLast Name
Home Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Cell Phone Number
Area CodePhone Number
Home Phone Number
Area CodePhone Number
Work Phone Number
Area CodePhone Number
Is it OK to call your work phone number?
YesNo
E-mail
Is it OK to email you?
YesNo
Is it OK to share this email with the other party ?
YesNo
Date of Birth
MonthDayYear
Date
Place of Birth
Place
Education
Choose from selection
If graduate school what type?
Marriage Date
MonthDayYear
Date
Where were you married?
Ceremony or Civil Service?
Choose from selection
Children from present marriage and stepchildren living in household:
Full Name Date of Birth School Grade SSN
Child #1
Child #2
Child #3
Child #4
Child #5
If additonal children from present marriage living in household:
Do any of the children have special education or special medical needs ?
YesNo
If answered with "yes" please specify
What kind of special education or special medical needs does your child have?
What best describes your children's knowledge of your marital situation?
Do you anticipate a dispute about custody of the children?
YesNoPossibly
Who initiated the idea of separation or divorce?
SelfSpouse
What was the other person's reaction?
Are you presently living with your spouse?
YesNo
If you answered "No" when did you separate?
MonthDayYear
Date
If not living together who initiated?
SelfSpouseMutual
Whose idea was it to start divorce mediation?
SelfSpouseMutual
Who referred you to Rebalancing America and Beyond?
What best describes your current situation?
Tell us one positive thing about the other party:
Are there any legal reasons that prevent you communicating directly or indirectly (ex:Order of Protection)?
Indicate below the names and approximate date of last contact you had with:
1) A marriage counselor or therapist who both you and your spouse saw:
Name of counselor or therapist
1a) Approximate date of last contact
MonthDayYear
Date
2) An individual therapist who you have seen or presently see :
Name of individual therapist
2a) Approximate date of last contact
MonthDayYear
Date
3) An attorney who you consulted about separation or divorce:
Name of attorney
3a) Approximate date of last contact
MonthDayYear
Date
Employment Information
Your occupation
Job Title
Name of Employer
Work Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
How long at present Job?
What is your gross salary?
Yearly
Any other regular income?
YesNo
If yes please enter the amount?
Yearly
If yes please enter the source?
Does your employer provide?
Medical InsuranceLife InsuranceAuto InsurancePensionSaving PlanStock Rights401k PlanOther
If "Other" please specify
Family Finances
Do you own any of the following?
HouseVacation HomeBoatAntiquesCollectiblesBusinessCars
If you checked "Business" please describe:
If you have checked "Cars" please describe:
Do you own any of the following?
Bank Accounts
Enter Value
Checking
Saving
Investments
Enter Value
Stocks
Bonds
Mutual Funds
Other
Private Retirement
Enter Value
IRA
401 K / 403 B
Other
Do you any major debts?
YesNo
If yes please describe:
Household finances have been previously handled by:
SelfSpouseMutual
Health Insurance
Name of the plan:
Your ID#
Is coverage provided by:
Your EmployerYourselfSpouse's EmployerSpouse
Does insurance cover your children?
YesNoDoes not apply
Prior Marriages
List any prior marriages and indicate if there are any children, their ages and who they live with. Please describe any financial arrangements between you and your former spouse:
Please provide a brief history of your current marriage / relationship :
What are the issue that you want to discuss in mediation and descirbe why it is important to you:
Do you have any concerns about being in the same room with your former partner?
What do you consider to be the gratest obstacle in reaching an agreement in mediation?
Indicate the reasons that best explain your reasons for separating :
Poor communicationThreatsEmotional abuseDrugs / alcohol abuseIncompatibilityMental illnessGreat deal of conflictInfidelityPhisical abuse / violenceGrown apartOther
If other please describe:
Is there any Police Record on file?
YesNo
Is there any CPS case on file?
YesNo
Do you have any disabilities you would like us to know about?:
Anything Else?
Are ther any other facts or circumstences that are relevant to your seeking mediation at this time?
Should be Empty:

	Full Name	Date of Birth	School	Grade	SSN
Child #1
Child #2
Child #3
Child #4
Child #5

	Enter Value
Checking
Saving

	Enter Value
Stocks
Bonds
Mutual Funds
Other

	Enter Value
IRA
401 K / 403 B
Other

Mediation Client Intake Form 3

Employment Information

Family Finances

Health Insurance

Prior Marriages

Anything Else?