Name

Your Street Address, Town/City, Postal Code

Email Address

Phone Number

Preferred method of contact Preferred method of contactPhoneEmail

Occupation

List Child(ren): Name (DOB); Name (DOB)

Name of Lawyer

Who were you referred by?

Name of Other Parent

Other Parent's Street Address, Town/City, Postal Code

Other Parent's Email Address

Other Parent's Phone Number

Other Parent's Occupation

Other Parent's Lawyer

Date of Marriage/Start of Relationship

Date of Separation

Living arrangements Living arrangementsSame houseSeparate residencesOther

Do you have a signed Parenting Plan? Do you have a signed Parenting Plan?YesNoOther

What is your current parenting schedule?

Have you completed the division of assets? Have you completed the division of assets?YesNo

Have you determined child support? Have you determined child support?YesNo

Describe how you and your former partner are communicating about the children:

What are your biggest concerns for your children right now?

What are the specific issues you would like addressed in mediation/parenting coordination?

Have there been any incidents of violence between you and your former partner? Select all that apply: Have there been any incidents of violence between you and your former partner? Select all that apply: Physical Verbal Emotional Sexual None

If YES, please specify when: If YES, please specify when: In the past 6 months More than 6 months ago

Please provide details:

Have the children WITNESSED any incidents of violence? Have the children WITNESSED any incidents of violence? Physical Verbal Emotional Sexual None

If YES, please specify when: If YES, please specify when: In the past 6 months More than 6 months ago

Please provide details:

Have the children EXPERIENCED any incidents of violence? Have the children EXPERIENCED any incidents of violence? Physical Verbal Emotional Sexual None

If YES, please specify when: If YES, please specify when: In the past 6 months More than 6 months ago

Please provide details:

Are you afraid of the other parent for any reason? Are you afraid of the other parent for any reason?YesNo

If YES, please provide details:

Have you ever called the police, requested a protection order, or sought help for yourself as a result of violence by the other parent? Have you ever called the police, requested a protection order, or sought help for yourself as a result of violence by the other parent?YesNo

If YES, please provide details:

Have you or the other parent abused alcohol or drugs (including prescription)? Have you or the other parent abused alcohol or drugs (including prescription)? YesNo

If YES, please provide details:

Has the other parent ever threatened to deny you access to your children? Has the other parent ever threatened to deny you access to your children?YesNo

If YES, please provide details:

Do you have any concerns about the children's emotional or physical safety with you or the other parent? Do you have any concerns about the children's emotional or physical safety with you or the other parent?YesNo

If YES, please provide details:

Have you ever undergone treatment for substance abuse? Have you ever undergone treatment for substance abuse?YesNo

If YES, please indicate when:

Have you ever been arrested for an alcohol related crime? Have you ever been arrested for an alcohol related crime?YesNo

If YES, please provide details:

Are you now, or have you ever been on probation or parole? Are you now, or have you ever been on probation or parole?YesNo

If YES, please provide details:

Have you ever had a restraining order filed against you? Have you ever had a restraining order filed against you?YesNo

If YES, please provide details:

Are you involved in a restraining order that is in effect right now? If so, please provide details:

Have you or the other parent participated in Domestic Violence classes, Batterer's Intervention or Anger Management classes? Have you or the other parent participated in Domestic Violence classes, Batterer's Intervention or Anger Management classes?YesNo

If YES, when and where?

Have there ever been charges filed against you for: Have there ever been charges filed against you for: Physical Assault Battery Domestic Violence Stalking None

If YES, please provide details:

Please share any additional concerns or comments: