Mediation Intake Form Step 1 of 6 - Client Profile 16% A. Client ProfileFull Legal Name First Middle Last Suffix Preferred Name First Last Date of BirthSocial Security Number: (secured)Best Contact NumberAlt Contact NumberOK to Leave a Voice Mail?YesNoEmail Address Street Address City County State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Co-Parent's NameDate 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 Edit Delete There are no Children. Add Child Maximum number of children reached. In Case of EmergencyEmergency Contact Name Last Emergency Contact PhoneRelationship to YouHow 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 B. Tell Us About YourselfReligious affiliation:ChristianJewishMuslimBuddhistHinduNoneInvolvement: None Some/Irregular Active How important are spiritual concerns in your life?Ethnicity/National origin:Race:Other important way you identify yourself: C. Health InformationPlease 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 SupportWho 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: E. Issues to be addressed (please check all that apply)Issues to be addressed Communication Decision-making Parenting time schedule Specific details of the parenting plan Division of personal property Division of assets and liabilities Provision of child support Provision of spousal support Payment for children's expenses Children's academics and school environment Children's health Children's extra-curricular activities Specific details of division of finances New relationships Living situation/moving Other:Have you previously used mediation to resolve a dispute? Yes No Please explain: F. Stress / Safety QuestionnaireHow do you ususally handle disagreements with your co-parent:Do you ever feel afraid of the other party? Yes No Has the other party ever threatened or hurt you? Yes No Do you or the other party have issues with drugs or alcohol? Yes No Please explain:Have you ever felt in danger of physical harm from the other party? Yes No Have you ever harmed or thought of harming the other party? Yes No Have you ever felt out of control with this other party? Yes No Has this other party ever seemed out of control around you? Yes No Has the other party ever slapped, pushed, hit or shoved you? Yes No Have you ever slapped, pushed, hit or shoved the other party? Yes No Are you worried about what might happen if you express yourself openly or disagree with the other party in mediation? Yes No This iframe contains the logic required to handle Ajax powered Gravity Forms.
