Step 1 of 4 25% Please take a few moments to answer this questionnaire. This document is strictly confidential and will be seen only by our office personnel. Please mark clearly any information, which you are uncomfortable discussing with the other party in mediation.Today’s date* MM slash DD slash YYYY *Please help us understand what type of family mediation you need assistance with.Please help us understand what type of family mediation you need assistance with* On-site court mediation-you have a pending court date, so someone (court staff, judge, lawyer) recommended mediation in regard to all issues related to your children. Off site-you are not in court you have issues to resolve for your children spousal support and or property financial issues. Upcoming Court Date:* MM slash DD slash YYYY Purpose What is current Court Order or Agreement? Is it being followed at this time? Referred By* Judge Lawyer Self Courts Staff Other General InformationName* First Last Date Of Birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Email* Employer* Job Title* If you have retained a lawyer, please provide name Name of any lawyer(s) consulted – or Legal Aid* Name of person you would like to settle issues with* Are there any legal reasons that will prevent you from communicating directly or indirectly with this person?*Any special circumstances, Language, accessibility* Date of Marrige* MM slash DD slash YYYY Live Together Since* Date of Separation* MM slash DD slash YYYY Divorced* ChildrenChild Name (1) Child (1) Date of Birth MM slash DD slash YYYY Child (1) Age Child (1) Living With Child (1) Grade Child Name (2) Child (2) Date of Birth MM slash DD slash YYYY Child (2) Age Child (2) Living With Child (2) Grade Child Name (3) Child (3) Date of Birth MM slash DD slash YYYY Child (3) Age Child (3) Living With Child (3) Grade Child Name (4) Child (4) Date of Birth MM slash DD slash YYYY Child (4) Age Child (4) Living With Child (4) Grade What are the main issues for mediation?* Most major issues, or most import issues*
