Submit Your Case, Confidential Mediation Form

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SUBMIT YOUR CASE

CONFIDENTIAL MEDIATION FORM

The information provided on this form is not shared with the other party. This information is protected by mediation confidentiality privileges and is used only for the process of gathering factual information about your case. Have a question don’t hesitate to call, click call now below.

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LEGAL LAST NAME, FIRST NAME *

ADDRESS *

City, State and Zip Code *

Your Phone Number *

Your Email *

Other Party's Last Name and First Name *

Other Party's Address *

Other Party's City, State, and Zip code

Other Party's Phone Number *

Other Party's Email address *

Petition the Court for:

Dissolution of Marriage
Legal Separation
Paternity Matter/Unmarried

Date of Marriage *

Date of Separation *

What county do you reside in? *

Are you or the other party represented by an attorney?

Yes
No

Is the other party agreeable with mediation?

Yes
No
I don't know

Is this your first time in a mediation.

Yes
No

Are there retirement accounts to be divided?

401(k) Pension Plans
IRA or Stocks
None

Do you have minor children?

Yes
No

Name, Date of birth(s), Age(s) of child(ren)

What city and state were the child(ren) born in? *

Address or addresses that the child(ren) have resided at in the past five years?

Are both parties requesting joint legal and physical custody of the child(ren), explain?

Describe the current parenting plan.

Are you Requesting Spousal Support?

Yes
I don't know
No

Is the other party requesting Spousal Support?

Yes
I don't know
No

Are you Requesting Child Support?

Yes
I don't know
No

Is the other party requesting Child Support?

Yes
I don't know
No

Are you currently living in the same house?

Yes
No

Have you moved out of the family residence?

Yes
No

Is there a prenuptial agreement?

Yes
No

Other Requests: Things you would like the Mediator to know.

What are the assets in the case, i.e., property?

What are your main concerns and interest for the case?

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