Family Mediation Intake Form
This document is strictly confidential, and is provided to us as a 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 help us assign the best-suited mediator to your file. It will be read only by the mediator and our staff.
How did you hear about our services? _____ Court Order
_____ Newspaper Ad
_____ Public Transit Ad
_____ Online
_____ Word of mouth (referral)
_____ Other (please specify)
GENERAL INFORMATION
Date: _________________
Court File No: __________
Status of File: __________
Name: ____________________________
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: _____________________________________________
Annual Income: ____________________________________________
Work Telephone: ____________
Ok to Call work? Yes______ No________
What is your first language? ____________________________
Date of marriage/cohabitation: __________________________
Date of separation: ___________________________________
Your Lawyer: _______________________________________
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 bond)?: ____________________________________________
Who made the decision to end the relationship? ________________________________
Tell us one positive thing about the other party:
____________________________________________________________________________________________________________________________________________________
Please provide a brief history of your marriage / relationship:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Children
Are there children from this marriage / relationship?
Yes____ No_____
If yes, please specify below:
Child’s Name
Age
Child is living with
1. _______________________________________________________________________
2. _______________________________________________________________________
3. ________________________________________________________________________
Do you have children from any other relationship?
Yes_____ No_____
If yes, please specify below:
Child’s Name
Age
Child is living with:
1. _________________________________________________________________
2. _________________________________________________________________
3. _________________________________________________________________
What are the issues that you want to discuss in mediation?
Issue
Why is this important to you?
a. ________________________________ ___________________________________
b. ________________________________ ___________________________________
c. ________________________________ ___________________________________
d. ________________________________ ___________________________________
Do you have any concerns about being in the same room with your former partner?
Yes______ No______
If yes, please explain below:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________
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 person
_____Other:
Is there any
a) Police File?
Yes______ No______
b) CAS file? Yes______ No______
ASSET/DEBT INFORMATION
REAL ESTATE
Do you own your home? Yes _____ No_____
Date Purchased: ______________________
How is the property titled? For example, is it held solely in one of your names or jointly
held in both ________________________
Approximate amount of the mortgage left to pay: _____________________
Approximate Fair Market Value: ___________________________
Do you own any additional real estate? _________Date Purchased: _________________
How is the property titled? Solely held in one name or jointly in both your names? _________________________________________________________________________
Approximate amount of the mortgage: ______________________
Approximate Fair Market Value: ___________________________
CASH AND BANK ACCOUNTS
Cash: $____________________
Please list all known bank account information:
Name of Bank:_______________________ Type of Account: ______________________
Account Number: ____________________ Balance: _____________________________
How held? Just your name _________; Both you and your spouse___________________
You and any person other than your spouse, please identify that person _______________
Name of Bank:_______________________ Type of Account: ______________________
Account Number: ____________________ Balance: _____________________________
How held? Just your name _________; Both you and your spouse___________________
You and any person other than your spouse, please identify that person _______________
Name of Bank:_______________________ Type of Account: ______________________
Account Number: ____________________ Balance: _____________________________
How held? Just your name _________; Both you and your spouse___________________
You and any person other than your spouse, please identify that person _______________
Name of Bank:_______________________ Type of Account: ______________________
Account Number: ____________________ Balance: _____________________________
How held? Just your name _________; Both you and your spouse___________________
You and any person other than your spouse, please identify that person _______________
INVESTMENTS: SECURITIES, STOCKS, AND BONDS
Name of Company:___________________ Type of Investment:_______________________
Name(s) on account: _________________________________________________________
Account Value: _____________________________
Dates of Accrual: ____________________________
Name of Company:___________________ Type of Investment:_______________________
Name(s) on account: _________________________________________________________
Account Value: _____________________________
Dates of Accrual: ____________________________
Name of Company:___________________ Type of Investment:_______________________
Name(s) on account: _________________________________________________________
Account Value: _____________________________
Dates of Accrual: ____________________________
RETIREMENT ACCOUNTS, PENSIONS, ANNUITIES
Type:______________________________ Name:__________________________________
Account Number:____________________ Owner: _________________________________
Account Value: _____________________ Beneficiary: _____________________________
Dates of Accrual: ____________________________
Type:______________________________ Name:__________________________________
Account Number:____________________ Owner: _________________________________
Account Value: _____________________ Beneficiary: _____________________________
Dates of Accrual: ____________________________
Type:______________________________ Name:__________________________________
Account Number:____________________ Owner: _________________________________
Account Value:______________________ Beneficiary: _____________________________
Dates of Accrual: ____________________________
VEHICLES (CARS, BOATS, ETC.)
Make/Model/Year/How Titled (jointly or separately)
Est Value:___________ Amount Owed:______________
Monthly Payment:_______________
Make/Model/Year/ How Titled (jointly or separately)
Est Value:____________ Amount Owed:______________
Monthly Payment:_______________
Make/Model/Year/ How Titled (jointly or separately)
Est Value:____________ Amount Owed:______________
Monthly Payment:_______________
CREDIT CARDS
Lender/Creditor:____________________ Amount:__________________
Name: ____________________________ Account Number:____________________
Responsible Party(s): ______________________________
Lender/Creditor:____________________ Amount:__________________
Name: ____________________________ Account Number:____________________
Responsible Party(s): ______________________________
Lender/Creditor:____________________ Amount:__________________
Name: ____________________________ Account Number:____________________
Responsible Party(s): ______________________________
Lender/Creditor:____________________ Amount:__________________
Name: ____________________________ Account Number:____________________
Responsible Party(s): ______________________________
OTHER ASSETS
Furniture/Household Items:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Jewelry: _______________________________________________________________________
Other Personal Property:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
NON-MARITAL PROPERTY
Non-Marital Property is property that fits into several categories, such as:
-
Things you owned before your marriage,
-
Gifts, inheritance, bequests made by a third party to you but not your spouse,
-
Things you got in exchange for your non-marital property,
-
Appreciated value in your non-marital property,
-
Things designated as non-marital property in a valid pre-nuptial contract.
Please list:
__________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What are the issues you wish to discuss in mediation?
__________________________________________________________________________
__________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Do you have any disabilities you would like to inform us about?
__________________________________________________________________________
Is there anything else you would like us to know?
__________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Please bring your last three (3) pay stubs, your most recent tax return, your
most recent statements for all retirement and investment accounts.
Yes______ No______
Do you have any disabilities you would like us to know about?
Yes_____ No _____
If yes, please explain below:
​
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Is there anything else you want us to know? Yes _____ No _____
If yes, please explain:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________
Download, complete and email this form to us at staff@invictuswyo.com