Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Name of Opposing Party
*
First Name
Last Name
Parties' Relationship Status:
*
Date Relationship Began
*
MM
DD
YYYY
Date of Separation
*
MM
DD
YYYY
Date of Divorce (if applicable)
MM
DD
YYYY
List Child(ren) in common, their ages, and with whom they are living
*
If you are remarried, your spouse's name, age, and the date of your marriage
Have you previously been in mediation? If yes, note the date of mediation, the mediator's name, and the location of the mediation
Do you have concerns about the child(red)'s emotional and/or physical safety with the other parent? Please explain in detail.
*
Do any of your children have any special needs or requirements which need special attention, equipment, or medication? Please explain in detail.
*
Do you have concerns about the other parent’s ability to provide the special attention, equipment or medication your child(ren) requires? Please explain in detail.
*
Has the Department of Children and Family Services been involved with the family regarding allegations of abuse and/or neglect of the child(ren)? Please explain in detail.
*
Has an attorney/Guardian ad Litem been appointed to represent the children? Please explain in detail.
*
Have you ever feared that you would not have access to your child(ren)? Please explain in detail.
*
Has any family member ever had counseling, medication or hospitalization for mental health reasons? Please explain in detail.
*
If a family member is on medication for mental health reasons, do they take their medication as directed by their doctor? Please explain in detail.
*
Do you have concerns regarding the use of alcohol and/or drugs in the family? Please explain in detail.
*
Has the other parent ever damaged or destroyed yours or your child(ren)’s property or harmed or threatened to harm yours or your child(ren)’s pets? Please explain in detail.
*
Has there ever been a physical confrontation between you and the other parent? Please explain in detail.
*
Has your child(ren) witnessed a physical confrontation between you and the other parent? Please explain in detail.
*
Do you have any concerns about your own emotional and/or physical safety with the other parent? Please explain in detail.
*
Are there now, or have there been, Orders of Protection? Please explain in detail.
*
Are you in any way afraid to meet with the other parent and the mediator? Please explain in detail.
*
Do you feel you were an equal partner in your relationship? Please explain in detail.
*
Could you speak your mind freely, express your point of view and have equal say in the decision-making process with the other parent? Please explain in detail.
*
Has the other parent ever prevented you from having contact with family, friends or with your child(ren)? Please explain in detail.
*
Do you feel you are ready to begin working with the other parent to develop a parenting plan? Please explain in detail.
*
Do you have any fear about answering these questions? Please explain in detail.
*
Is there anything else you would like to say?
