Mediation Intake Form printable pdf download

Mediation Intake Form

Confidential: Not to be Shared with the Other Party. Please Print.

(Note: We need to assess the level and potential of any abuse (if any) in the martial relationship

and establish boundaries about safety before issues can be mediated)

Name ______________________________________________________Date______________________

Address ______________________________________________________________________________

City________________________________ State______________ ZIP ____________________________

Home Phone _____________________________ Cell Phone ___________________________________

Work Phone _____________________________ Email ________________________________________

Name of Employer____________________________________ Position___________________________

Full Time Part Time Number of Years Employed __________________ Date of Birth ___________

Name of Spouse _______________________________________________________________________

Date of Marriage __________________ City & State of Marriage ________________________

Names and Ages of Children ______________________________________________________________

If Petition is filed, with which Court? _____________________ Case Number _____________________

Was abuse present in the marriage relationship? Yes

No

If so,  Physical  Emotional  Chemical  Other _______________________________________

Is there an Order for Protection or Restraining Order? _________________________________________

Have you had, or are you now in counseling, therapy and/or treatment program? Yes  No  If Yes,

what kind, with whom and for how long? __________________________________________________

____________________________________________________________________________________

Do you have an attorney? Yes

No If Yes, who? ________________________________________

Retained

Consulting

How did you find out about us?___________________________________________________________

If referred by an individual, may we send them a thank you note? Yes

No

Areas of greatest concern about the divorce

_____________________________________________________________________________________

Please return to:

Steve McBride, Steve McBride LLC, 7955 E Arapahoe Court, Ste 3000, Centennial, CO 80112

Phone: 303 867 1400 FAX 303 800 8230 Email:

Mediation Intake Form