Divorce Mediation Questionnaire

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Date Submitted: 05/16/2012 12:46 AM

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Divorce Mediation Questionnaire.

Please fill this out even if you think you have answered these questions on a prior intake form with this office.

1. Your full name _____________ and Maiden Name._______________ DOB._____

2. Place of birth._________. SS#_________ Date of Marriage ________

3. Place of Marriage _________________ Date of Separation ___________

4. Did you complete High School Y/N If yes, What is your highest grade 13,14,15

5. Did you complete college Y/N . What School or University ____________ Date of completion and Degree in what._____________________________

6. Your Place of employment.______________________ Full/Part time_________

7. Your current address. ___________________ Phone number ________Cell_________

8. Please list the names of all children from this marriage and there date of birth and place of birth and there S.S. numbers.

1. ____________ ___________________ _______________

2. ____________ ________________ __________________

3. ____________ ________________ ___________________

9. Are both parents still in same household Y/N If no please list the parent who is no longer in household and a current address for them and the date of move out.

10. Is this the first marriage for both parties? Y/N. If no please list all prior marriage’s and dates of divorce and if there are any children from the marriage and the dates of birth and who they are living with.____________________________________________


11. Do you want to reconcile Y/N?

12. Have you or the family had any family counseling prior to this meeting? Y/N. If yes please list name or name of people who were seen and the name of the counselor with the date of first appointment and ending date.


13. Do you or your spouse have a person/ attorney that is handling your divorce? Y/N if yes please list the name and...