DIVORCE MEDIATION INTAKE FORM

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First Name*
First
Last Name*
Last
Where are you in the divorce process?*
Do you both want to mediate your divorce?*
Has your spouse agreed to attend the consultation?*
Have you tried marriage counseling?*
Spouse's First Name*
First
Spouse's Last Name*
Last
Have you consulted with an attorney?*
Is there a current restraining order in effect?*
Years Married*
Your current address*
Street Address City State / Province / Region ZIP / Postal Code
Email address*
Phone Number*
Your Age*
Are you still living together?*
If not still living together, what is the date you separated?
Spouse's Full Address (if different than yours)*
Street Address City State / Province / Region ZIP / Postal Code
Spouse's Email*
Spouse's Phone*
Spouse's Age*
Do you have minor age children?*
Do you and your spouse own a home together?*
Do you own additional properties?*
Do either of you have a pension from a current or previous employer*
Total credit card debt you and your spouse have?*
Your employment status*
Your annual based salary*
Is your income variable or commission-based?*
Do you receive a bonus?*
Spouse's employment status*
Spouse's annual based salary*
Is spouse's income variable or commission-based?*
Does your spouse receive a bonus?*
Do you and/or your spouse own a business?*
What is your current time sharing with children arrangement?*
Are you satisfied with these arrangements? Please describe:*
What changes would improve your current time sharing arrangements?*
Does your work schedule affect your available time with children?*
What aspect of the divorce process is MOST important to you?*
Who referred you to us?*
Why are you considering working with us?*