THIS FORM IS FOR THE MEDIATOR'S USE ONLY.

The form addresses some topics which may be sensitive for you. Please answer as openly and honestly as possible so that we can design the mediation process in the most appropriate way for your family.

None of the information provided in this form will be shared with the other party or any other person. The form is private, confidential, Level 1 PCI compliant, and uses 128 bit SSL encryption.

Please fill out each section that applies to your situation and leave any inapplicable sections blank.

Your Phone
Your Phone
Your Address
Your Address
Your Birthdate
Your Birthdate
Date of Cohabitation (past or intended)
Date of Cohabitation (past or intended)
Date of Marriage (past or intended)
Date of Marriage (past or intended)
Describe any words or topics which may be emotionally difficult for you.
Which of the following does your relationship include?
Check all that apply.
Have you or the other person ever been criminally charged?
How would you describe your feelings about discussing the terms of a Cohabitation Agreement?
Check all that apply.
If you were not referred, how did you find us?