INTAKE FORM 

To initiate the mediation process, the following must be provided

  NAME                                                                        

ADDRESS                                                                         

CITY                                                                               

– STATE – ZIP                                                              

HOME PHONE                                                             

WORK PHONE                                                         

      E-MAIL                                                                 

ATTORNEY                                                                   

INTAKE FORM-PAGE 2

 (CONFIDENTIAL-not to be shared with other party)

DATE OF MARRIAGE (or date started being a couple together?):                                                                  

DATE OF SEPARATION (or date last living together?):                 

NAMES AND AGES OF CHILD(REN):

NAME AGEDOB

NAME AGEDOB

NAME AGEDOB

NAME AGEDOB

IS A RESTRAINING ORDER IN PLACE, 

 YES NO2

EXPLAIN 

WAS ABUSE PRESENT IN MARRIAGE?          

YES NO3   

IF YES PLEASE  CLICK HERE

DO YOU HAVE AN ATTORNEY?  

YES NO4

IF YES, WHO? 

HAVE YOU BEEN IN COURT RECENTLY?   

For  CHILD CUSTODY , CHILD SUPPORT or any other reason ?

YES NO5

EXPLAIN

HAVE YOU HAD OR ARE YOU OR YOUR CHILDREN NOW IN COUNSELING?   

IF YES, WITH WHOM? 

S32

HAVE YOU HAD OR ARE YOU OR YOUR CHILDREN NOW SEEING A DOCTOR? 

IF YES, WITH WHOM? 

S33

HAVE YOU HAD OR DO YOU OR YOUR CHILDREN NOW HAVE ANY MAJOR MEDICAL CONDITION THAT THE MEDIATOR SHOULD KNOW ABOUT?  

IF YES, WHAT? 

S34

HAVE YOU HAD OR ARE YOU OR YOUR CHILDREN NOW TAKING MEDICATION THAT THE MEDIATOR SHOULD KNOW ABOUT? 

 IF YES, WHAT?

Family Mediation Service currently provides mediation services and Wise Person counsel at a compensated rate of $125.00 PER HOUR PLUS TAX .

Sessions are usually one hour long, however, some may be shorter and some may be longer.  

Addition to compensation for the mediation session, the mediator's work outside of the mediation session will be paid for. (Such as necessary word processing work, phone calls associated with the case

(i.e., attorney consultations/psychiatric consultations/ social services consultations), and atypical photocopying needs associated with the case).  .

Billing is in quarter-hour increments (.25, .50, .75, 1.0, 1.25, etc.)

Fees are due and payable at the end of each session.  

3.    DOCUMENTS

SLIDING FEE IS NOT AVAILABLE FOR:  DOCUMENTS

If a document is produced, the fee for the document is $60.00 PLUS TAX.  

If a document is required, the document fee is due and payable when the first draft of the document is produced. 

Signature Date

   AGREEMENT TO MEDIATE 

PAGE 4

  This agreement to mediate is between  

Mother     

and

Father          

The parites by their signatures below have agreed to and sign this Agreement to Mediate with full knowledge of its contents and without coercion, duress or undue influence of any kind.

  Each party signs this Agreement to Mediate with full knowledge that the Mediator is not a lawyer and as such can give no legal advice.  Under no circumstance will the Mediator be deposed or required to testify in court.

  Each party signs this Agreement to Mediate with full knowledge that the Mediator is required to maintain confidentiality regarding the mediation proceedings.  Each party is fully informed of his /her right to confidentiality. 

  All client information is protected from illegal or unethical oral or written disclosure of any kind. 

Be fully informed that Family Mediation Service Staff is required by law to report any child abuse and neglect incidence to the Children Youth And Families Department.

I have read the above statement, or have had it read to me, and I consent to mediation with Family Mediation Project.

Signature Date     

Email

*REQUIRED FIELD* 

     FORM SUBMISSION