Intake For Family Mediation

This form is private and confidential. The only exception will be if the safety of a child is at risk or if there are threats of imminent harm to yourself or another person. Otherwise we will not share any of this information without your consent.

Providing this information will save time, and therefore fees, when we meet.

    Personal Information


    YesNo


    YesNo

    The Other Party


    YesNoUnknown


    YesNo

    Children

    Background Information


    YesNo


    YesNoUnknown


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo


    YesNo

    Issues for Mediation


    Physical abuse/violenceThreatsDrugs/alcohol abuseMental illnessInfidelityPoor communicationEmotional abuseIncompatibilityGreat deal of conflictTaking advantage of other personGrown apart/different goals in life


    Parenting TimeSpecial occasions, holidays, travelParent ResponsibilitiesCommunicationChild SupportExtraordinary and Special Expenses (ex. Childcare, health expenses, special needs)Other Expenses Related to the ChildrenSpousal SupportDivision of AssetsDivision of DebtsOther:


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    Not located in Victoria?

    No problem. I can arrange to mediate in your Vancouver Island or Gulf Island community.

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