Intake Questionnaire

Please take a few minutes to answer this questionnaire.

All information collected is strictly confidential and will be seen only by our office personnel.

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Today's Date

Referred By

About You

First Name *

Last Name *

Email Address *

Phone Number

Employer

Other Party Type (ie. Former Spouse)

Lawyer

Lawyer Phone Number

About the Relationship

Name of Other Party

Relationship

Date of marriage

Date of separation

Who made the decision to separate?

Reason for separation (select top 3)

my feelings changedwe grew apartpoor communication on my partI took advantage of my partnermy drug/alcohol problemmy adulterymy sexual problemsmy mental healthI was emotionally abusiveI was physically abusive

my partner's feelings changedgreat deal of conflictmy partner's poor communicationmy partner took advantage of memy partner's drug/alcohol problemmy partner's adulterymy partner's sexual problemsmy partner's mental healthmy partner was emotionally abusivemy partner was physically abusive

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

Please provide a brief history of your marriage/relationship

Please tell us one positive thing about the other party

What do you think are the most important issues for this mediation?

Are there children from this marriage/relationship?

Children Details (names, ages, who they are living with)

Have you started legal action in court?

If yes, what stage are you at:

Court file number (if applicable)

Next Court Date

Where does you annual income fall?

Is there anything else you would like us to know before scheduling our meeting?