Intake Form - proserv1 at Quarter

Step 1 of 7

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Name(Required)

First Last

Preferred Parental Title

Email(Required)

Enter Email Confirm Email

Referred By

Status of File

Court File Number

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Telephone Number

Mobile Number

Age

Consent

May we email you at the above address?

May we share this email with the other party?

Your Employer

Your Annual Income

Work Telephone Number

Preferred Language of Communication

Consent

May We Call You At Work?

Date of Marriage/Cohabitation

DD slash MM slash YYYY

Date of Separation

DD slash MM slash YYYY

Name of Lawyer

Name of Other Party

Party 2 - Annual Income

Reconciliation

Are you interested in reconciliation

Are you currently involved in a court proceeding for these issues?

Is there an existing separation agreement or court Order?

Are there any legal reason(s) preventing you from communicating directly or indirectly (restraining order/peace bond)?

Who made the decision to end the relationship?

Please tell us one positive thing about the other party.

Please provide a brief history of your marriage/relationship.

Are there children from this marriage?

Childs Name

Date of Birth

Age

Child is living with?

Do you have children from any other relationship(s)?

Childs Name

Date of Birth

Age

Child is living with?

What are the issues you wish to discuss in mediation?

Issue

Why is this important to you?

What is communication like with your partner?

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

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

Indicate the factors that best explain your reasons for separating.

Physical abuse / violence

Emotional abuse

Drug / alcohol abuse

Mental illness

Infidelity

Poor communication

Threats

Incompatibility

Great deal of conflict

Taking advantage of the other person

Other factors that best explain your reasons for separating:

Is there any

CAS file

Police File

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

Is there anything else you would like us to know?

How did you hear about Purdon Family Law Mediation

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Comments

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Purdon Family Mediation - Client Intake Form