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 former Partner

Former partner's Street Address, Town/City, Postal Code

Email Address

Phone number

Former Partner's occupation

Lawyer's name

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?

Date of Marriage/Start of Relationship

Date of Separation

Factors that contributed to the end of the relationship:

Have there been any incidents of violence in the relationship? Check all that apply: Have there been any incidents of violence in the relationship? Check all that apply: Physical Sexual Verbal Emotional None

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

Please give specifics of violence in the relationship.

Have the children WITNESSED any incidents of violence in the relationship? Have the children WITNESSED any incidents of violence in the relationship?YesNo

If so, please give specifics.

Have there been any incidents of violence TOWARD the children? Check all that apply: Have there been any incidents of violence TOWARD the children? Check all that apply: Physical Sexual Verbal Emotional None

If YES, please give specifics:

Are you fearful of the other parent for any reason? If YES, please give details:

Have you or the other parent abused alcohol or drugs (including prescription drugs?) If YES, please give details: