Please copy and paste the following form into your word processing program.
When you complete it you may bring it to your first appoinment.
COUNSELLING & MEDIATION SERVICES
Leland Clipperton, H.S.C.
Phone: 905-510-9117 (iphone)
Web Site: www.CounsellingandMediation.com
Counselling & Mediation Services
Intake /Screening Form
Please take a few moments to answer this questionnaire as completely as possible.
The information will assist us in facilitating the settlement discussions on your behalf.
This document is strictly confidential.
Please mark clearly any information which you are uncomfortable discussing with the other party in mediation .
This information is required by the Ministry of the Attorney General.
Today’s date: __________________
Referred to mediation by: ________________________
1.) GENERAL INFORMATION:
Your FULL NAME: _____________________________________________
Date of Birth: _______________________
Address: __________________________________Apt/Unit #________
City_______________________________ Postal Code ______ — ________
Telephone:__________________Alternate – Friends phone # ____-________
Cell Phone _______________________ Pager _______________________
Home Email ____________________________________
Your EMPLOYER: _____________________________________________
Telephone #________________ X ______
Okay to call you at work? Yes ____ No____
Work Email _________________________________
Retained now, Yes ___ No ___
Lawyers Telephone __________________
FORMER PARTNERS NAME: ______________________________________
Address:_____________________________________ Apt / Unit #_______
City ____________________________ Postal Code:_______________
Work Phone *_________________
* If you do not have a reliable method of contact please advise the intake mediator.
Do you have any interest in reconciliation with this person? Yes ____ No ____
Is your former partner aware of your interest in Mediation Yes _____ No _____
Have they made an Mediation Intake appointment Yes ____ No ____ Don’t know ____
If No or Don’t know: How would you like your former partner to be invited to participate?
a) I will ask, Yes ____ No ____ OR
b) Could the Counselling & Mediation Services contact them? Yes ___ No ____
2.) I NFORMATION FOR THE MEDIATOR
1. a) Did you and your former partner live together? YES ( ) NO ( ) if No go to b)*
When did you begin living common-law? ______ month _____ year
and /or What was your date of marriage? ______ month _____ year
b)* How long did you date / go out together ______ months _____ years – if No to 1a
c) When did you last separate / stop going together? _______ month ______ year
2. Are there children from the marriage/relationship with your former partner ?
NO ( ); if YES ( ) Please complete below.
|Child’s Full Name||M/F||Date of Birth||Age||Child now living with|
3. When reflecting on your marriage/relationship, what has been the most positive aspects and what has been the most negative ?
4. Are you currently in a new marriage/common-law relationship? YES ( ) NO ( )
If so, since when?_____________ Name of current partner:_______________________
Do you have other children not mentioned above? YES ( ) NO ( )
Children from this new relationship.
Please provide (with a simple explanation) what you perceive as the issues for Mediation..
Issues Why is this a Concern?
6. a) Have any legal proceedings commenced in court? YES ( ) NO ( )
If yes, please provide the following:
a. court file #________________
b. next court date _____________
c. order or agreement currently in force __________
b) Have you have signed Separation Agreement with your former partner? YES ( ) NO ( )
i. When was it signed ____________________________
ii. Are there issues that you would like to review or change in this agreement?
Please describe __________________________________________________________
7. a. Are you entering into mediation voluntarily? YES ( ) NO ( )
If No, Please explain:_____________________________________________________
b. Why have you chosen mediation to resolve your Family Law matter?
8. Are there any other significant adults involved in the care of your children?
(i.e. grandparents, other family members, daycare providers?)
9. What is the highest level of education you have completed? (circle number)
1. less than high school 2. high school diploma
3. some post-secondary schooling 4. college/technical degree
5. university degree, undergraduate 6. other ___________
10. In which of the following groups does your yearly gross income fall? (circle number)
1. less than $15,000 2. $15,000 – $29,999
3. $30,000 – $59,999 4. $60,000 or more
11. What is your yearly gross household income? (Income from all sources in your current home.
For example, new partner’s, workers compensation – all income other than child support.) (circle number)
1. less than$15,000 2. $15,000-$29,999
3. $30,000 – $59,999 4. $60,000 or more
12. Which of the following languages do you understand and speak the best?
1. English 2. French 3. other _____________
13. a) Which of the following best describes where you live at the moment?
1. housing owned with a mortgage 2. housing owned without a mortgage
3. housing rented privately 4. housing rented from Ontario Housing
5 friend/relative’s no rent 6. friend/relative paying rent
7. other ____________________________________
b) Are you currently living in the matrimonial home?
1. yes 2. no
c) At the time of your final separation, who moved out of the family home?
1. me 2. partner 3. both 4. neither
14. How old were you when you and your partner got married or began living together?
Me: __________ years old Partner:_________ years old
15. Who made the decision to separate?
1. me_______________ 2. partner ____________ 3. both__________
16. Couples who separate/divorce do so for a number of reasons. Please list the 3 which best suit your reasons for separating:
#1. Reason _____________________________________________________________
#2. Reason ______________________________________________________________
#3. Reason ______________________________________________________________
17. a) Are you and your partner living in separate residences at this time?
1. no (see c) 2. yes (see b)
b) If yes what date did you begin living separately?
month __________ year ________ .
c) If no please explain the current arrangements.
18. Who did the child(ren) live with when you separated?
1. me__________ 2. partner____________ 3. both ___________
19. Who are the child(ren) living with now?
1. me______ 2 partner________3. both _____ 4. other______
20. At the present time, with whom are you living? (circle any that apply)
1. new partner 2. parents
3. other relative 4. friends
5. alone 6. other (please specify): ____________________
21. When you were together, describe what would typically happen when either you or your
former partner became angry.
22. Describe any instances of verbal, emotional or physical abuse.
23. When you were together with your former partner, how did you manage your finances?
24. Between 1 and 10, what is your level of comfort in participating in mediating with your former
partner in the same room? ___________
25. How do you feel your former partner will comply with decisions made during the mediation?
26. Describe any misuse or abuse of drugs or alcohol in the relationship?
27. How were decisions made with your former partner?
28. What are you hoping to achieve from mediation?
Thank you for taking the time to complete this form.