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Mediation Intake Form
cfr-admin
2022-01-27T19:14:10-06:00
Mediation Intake Form
Step
1
of
6
- Client Profile
16%
A. Client Profile
Name of the CFR professional assisting you:
Amy Armstrong
Wendi Stern
Terri Johnston
Deb Frazier
Chris Farmer
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
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Name(s) of Other Party
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
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Children.
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Maximum number of children reached.
In Case of Emergency
Emergency Contact Name
Last
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
B. Tell Us About Yourself
Religious affiliation:
Christian
Jewish
Muslim
Buddhist
Hindu
None
Other
Involvement:
None
Some/Irregular
Active
How important are spiritual concerns in your life?
Ethnicity/National origin:
Race:
Other important way you identify yourself:
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 such as an attorney or support person?
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
Business transitions
Other:
Have you previously used mediation to resolve a dispute?
Yes
No
Please explain:
F. Stress / Safety Questionnaire
How do you ususally handle disagreements?
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
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