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GET STARTED WITH

Mediation Intake

Before you start make sure you

Schedule free consultation

Then fill out the form below

Personal information:

First name

Last name

Maiden name (if applicable)

Home address

Birthday

Code

Home phone number

Code

Cell number

Best way to contact

Leave voicemail on cell

Text message

Education:

High school

Bachelors

Years of college

Graduate school (type)

Graduate School

Marital information

Date of marriage

Street Address

Street Address Line 2

City

Region/State/Province

Country

Type of marriage

Civil union

Religious ceremony

Children from present marriage and stepchildren living in household:

Do any of the children have special education or special medial needs?

Who initiated the idea of marital mediation?

Self

Spouse/partner

What was the non-initiator's reaction?

Are you living with your spouse/partner?

Yes

If not, enter date of separation

Names and approximate date of last contact with a marriage counselor or therapist who both you and your spouse/partner saw:

Names and approximate date of last contact with an individual therapist who you have seen or currently see:

Names and approximate date of last contact with an attorney you consulted about separation or divorce:

Professional information

Your occupation

Job title

Name of your employer

Code

Your work number

Work address

How long at your present job?

Previous jobs held

(THIS INFORMATION IS CONFIDENTIAL AND WILL NOT BE SHARED WITH THE OTHER PARTY)

Describe the current conflicts in your marriage

How would your spouse/partner describe the current conflicts in your marriage?

What do you hope to achieve in Marital Mediation?

What obstacles if any do you feel you may face in achieving your goals?

Are there any other facts or circumstances that are relevant to your seeking mediation at this time?

We offer the option for you to choose 2 co-mediators (usually male & female) who will work together throughout the mediation. We'll provide further details about this during our evaluation call. Would you be interested in it?

Yes

ANDRÉ POLITZER

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