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Home
About
Services
Divorce Mediation
Post-Divorce Mediation
Parenting Mediation
Out of Marriage Mediation
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FAQ
Contact
Get Started
intake form
Mediation Intake Form
Personal Information
Name
(Required)
First
Last
Sex
(Required)
Male
Female
Other
Date of Birth
(Required)
Day
Day
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31
Month
Month
1
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Year
Year
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2026
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1927
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1920
Email
(Required)
Phone
(Required)
Address
(Required)
Street Address
Address Line 2
City
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Province
Postal Code
Job Title
(Required)
Place of Employment
(Required)
Approximate Annual Income
(Required)
Relationship Information
Marital/Relationship Status
(Required)
Single
In a relationship
Married
Separated
Divorced
Widowed
Date of Marriage
(Required)
MM slash DD slash YYYY
Did you live together in a committed relationship before marriage?
(Required)
Yes
No
When did that cohabitation begin?
(Required)
MM slash DD slash YYYY
Approximate date of separation
(Required)
MM slash DD slash YYYY
Describe the reasons for the separation
(Required)
Children
Do you have minor children you are seeking mediation for?
(Required)
Yes
No
Enter the information of the children involved
Name
(Required)
Full Legal Name
Age
(Required)
Untitled
Who do they live with now?
(Required)
With whom would you like them to live?
(Required)
Do you have children from outside of this relationship?
(Required)
Yes
No
Enter the information of the children from outside this relationship
Name
(Required)
Full Legal Name
Age
(Required)
Untitled
Counselling
Are you currently attending couple’s counseling?
Yes
No
Other
How long have you been attending?
(Required)
Counselor’s Name
(Required)
Counselor’s Contact Information
(Required)
Financial & Legal
Do you have significant assets?
(Required)
Yes
No
cars, matrimonial home, other properties, bank accounts, etc
Please describe
(Required)
Do you have significant debts?
(Required)
Yes
No
mortgages, lines of credit, loans, etc
Please describe
(Required)
Do you have an attorney retained?
(Required)
Yes
No
Attorney’s Name
(Required)
Attorney’s Contact Information
(Required)
Are there any active court cases involving this matter?
(Required)
Yes
No
File Number(s)
(Required)
Are there any restraining orders that may prevent mediation?
(Required)
Yes
No
Please describe
(Required)
Safety Concerns
Have there been any incidents of domestic violence involving you, your partner, or your children?
(Required)
Yes
No
Nature of incident(s)
(Required)
When did it occur?
(Required)
If it is still occurring
(Required)
Do you fear for your safety?
(Required)
Mediation Topics
Please check off all topics you want to discuss in mediation
(Required)
Parenting Schedules
Decision-Making for Your Children
Child Support
Spousal Support
Division of Assets and Debts
The Future of the Matrimonial Home
Other
Other: Please specify
