FAMILY MEDIATION FORM 1:
INTAKE

To send New Solution Mediation your intake information, you may use the form below.
Alternately, you may download this Form in Word doc format and follow the attached instructions for emailing it to New Solution Mediation.
Note that this information is strictly confidential, and is for the use of New Solution Mediation only –your information will not be shared with the other party or his/her counsel without your permission.

Please also see Family Mediation FORM 2: Income & Assets which covers much of the common ground for Family, Separation and Divorce Mediation.

Client Information

Your Name (*required)

Birthdate:

Residence address incl. postal code

Mailing address incl. postal code (if different from above)

Primary phone (*required)

Is it ok to call and leave messages at this number?

Cell phone (if different from Primary phone)

Is it ok to call and leave messages at this number?

Work phone

Is it ok to call and leave messages at this number?

Email (*required)

Is it ok to send emails to this address?

Employer/job

Annual income

What is your first language?

Lawyer's name

Emergency Contact's name

Emergency Contact phone

Emergency contact email

How did you hear about us?

Other Party Information

Other party's name

Birthdate:

Address incl. postal code

His/her employer/job

Annual income

Relationship Information

Date of cohabitation

Date of marriage

Marriage location

Date of separation

Are you interested in reconciling with the other party?

Who made the decision to separate?

Specify the reasons for separating:

Are there any legal reasons that prevent you from communicating directly with the other party (ex. no contact order)?

Do you have any concerns about meeting in the same room with the other party in a mediation setting? If so, please describe:

Is there anything in your past relationship that would prevent you from speaking clearly about your needs and listening attentively to the needs of the other party? If so, please describe:

What issues need to be settled between you?

Is there anything else you want us to know?

Children

List all the children of the relationship.

Child 1 Full name

Child 1 Birthdate:

Child 1 Grade

Child 1 resides with

Child 2 Full name

Child 2 Birthdate:

Child 2 Grade

Child 2 resides with

Child 3 Full name

Child 3 Birthdate:

Child 3 Grade

Child 3 resides with

Child 4 Full name

Child 4 Birthdate:

Child 4 Grade

Child 4 resides with

Child 5 Full name

Child 5 Birthdate:

Child 5 Grade

Child 5 resides with

List all the children from other relationships.

Child 1 Full name

Child 1 Birthdate:

Child 1 Grade

Child 1 resides with

Child 2 Full name

Child 2 Birthdate:

Child 2 Grade

Child 2 resides with

Child 3 Full name

Child 3 Birthdate:

Child 3 Grade

Child 3 resides with

Child 4 Full name

Child 4 Birthdate:

Child 4 Grade

Child 4 resides with

Child 5 Full name

Child 5 Birthdate:

Child 5 Grade

Child 5 resides with

FAMILY MEDIATION FORM 1: INTAKE

Client Information

Other Party Information

Relationship Information

Children

FAMILY MEDIATION FORM 1:
INTAKE