Mediation Intake Form

A. Client Profile

Name of the CFR professional assisting you:

Amy Armstrong

Wendi Stern

Terri Johnston

Deb Frazier

Bobbie O'Keefe

Full Legal Name(Required)

First Middle Last Suffix

Preferred Name

First Last

Date of Birth(Required)

Social Security Number: (secured)(Required)

Best Contact Number(Required)

Alt Contact Number

OK to Leave a Voice Mail?

Yes

No

Email(Required)

Address(Required)

Street Address Address Line 2 State ZIP Code

Co-Parent's Name

Date and City/State of Marriage (if applicable):

Children?

Check if applicable

Children's Name and Date of Birth

Child's Name	Child's Date of Birth	Actions

There are no Children.

In Case of Emergency

Emergency Contact Name

Emergency Contact Phone

Relationship to You

How did you hear about The Center for Family Resolution?

If referred, by whom?

May I have permission to thank this person for the referral?

Yes

No

C. Health Information

Please list any medical concerns that may pertain to you or the other involved party:

Please list any mental health concerns that may pertain to you or the other involved party:

How do you manage stress? How will the mediator know if you become overwhelmed, exhausted or are no longer thinking clearly?

D. Participation and Support

Who will participate in the mediation with you?

Would you like to utilize a process where each party has his or her own coach or advocate (co-resolution)?

Are you working with an attorney?

Yes

No

Name of attorney:

A. Client Profile

B. Tell Us About Yourself

C. Health Information

D. Participation and Support

E. Issues to be addressed (please check all that apply)

F. Stress / Safety Questionnaire

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