FAMILY MEDIATION INTAKE FORM
This document is strictly confidential, and is provided to us as part of a confidential   (closed) mediation   process. The  only  exceptions   are  if  a  child is  at
risk of harm, any person is in imminent danger or a judge orders disclosure of this information. It will be read only by the mediator and our staff.

Date	 Court File No:  	 Name  	

Referred By  	Status of file  	 Age  	

Address   	

Telephone	Cell  Email	 Is it ok to email you at the above address?        Yes   No 
Is it ok to share this email with the other party?      Yes    No 

Employer/ Job  	nual Income  	
Work Telephone 	Ok to call work?	Yes     No 
What is your first language?  		  Date of marriage/cohabitation _________Date of separation ______________	our Lawyer  		

THE OTHER PARTY

Other Party Name	Age  	

His/Her Employer/ Job/ Annual Income  Do you have interest in reconciliation with this person?  			 Are there any legal reasons that prevent you from communicating directly or indirectly (restraining order/ peace letter)?  	
Who made the decision to end the relationship?  	

	1

Tell us one positive thing about the other party.  	
Please provide a brief history of your marriage / relationship: (next page)

      Are there children from this marriage / relationship?
Child’s Name	Age	Child is living with

Do you have children from any other relationships?

Child’s Name	Age	Child is living with

What are the issues that you want to discuss in mediation?

Issue	Why is this important to you?

a.	 		 	

b.	 		 	

	2

c.	 		 	
d.	 		 	

Do  you  have  any  concerns  about  being  in  the  same  room  with  your  former partner?

What do you consider to be the greatest obstacle in reaching an agreement in mediation?

Indicate the reasons that best explain your reasons for separating.

__

__

_		Physical abuse / violence	_		Poor Communication

__

__

_		Threats	_		Emotional abuse

__

__

_		Drugs / alcohol abuse	_		Incompatibility

__

__

_		Mental illness	_		Great deal of conflict

__

__

_		Infidelity	_		Taking advantage of the other person

Other  	

Is there any	a) Police file	Yes 	No	
	b) CAS file	Yes 	No	

Do you have any disabilities you would like us to know about?

Is there anything else you want us to know?

Please send this completed form by e-mail or fax.