2 chairs and a table in a private setting

Full Name

Date of Birth

Month

Day

Year

Email

Phone Number

Country/region

Address

City

Postal Code

Preferred means of communication

Preferred times for appointments (weekday and time)

In an ideal world, what would you like your relationship with the other party to look like one year from now?

What would you like with respect to parenting time and decision making regarding your children?

What do you believe would be the best outcome in order for the mediation to be successful?

If C.A.S has been involved, have closed the file?

Do you work outside of the home? If yes, please list occupation below:

Annual Income

Date of Marriage if applicable

Date of Cohabitation

Separation Date if applicable

I have a prenup

I am still living in the same residence

I am sharing a residence with that person

I am in a significant relationship with another adult

If you have obtained legal or financial advise about your situation, please provide the professionals name and contact info.

Have you started any legal proceedings, and if so, what stage of court are you at?

Name of other party

Address of other party

Email address of other party

Phone number of other party

List children from this relationship (name, & date of birth)

Where do the children currently reside?

Are there any current parenting time & decision making responsibility (access or custody) arrangements? If so, please provide details

Other things you would like to discuss, if any

Emergency Contact (name and phone number)

How did you hear about our services?

What brought you to mediation?

Have you ever had mediation before? If so, please describe your experience.

What most concerns you with regards to your situation?

What are you hoping to get out of mediation?

Do you have any concerns regarding the children? If so, please provide details

Google Drive Link

I would like to discuss parenting time (access) of the children

I would like to discuss parenting time & decision making responsibility for the child(ren).

I would like to discuss spousal support

I would like to discuss the possession, ownership, equalization, and division of property

I would like to discuss child support

https://www.thecleandivorce.com/forms/contract-family-mediation-form

If this is your first session with us, please fill out our online Intake Interview using this link below (This is Required):

https://www.divorcepath.com/intake/the-clean-divorce

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About Suzanne

I’m Suzanne Winlove-Smith, an accredited Family Mediator, Relationship & Divorce Coach. I started The Clean Divorce when I came to realize how few resources were available to those going through relationship breakdown. When I was immersed in the experience of my own divorce, I saw how important it was to create a new way forward.

Working with couples in numerous court systems in Eastern Ontario equipped me with extensive skills in divorce support, counselling, and mediation. My experience with my own divorce gave me invaluable insight that has further inspired me to create simple and empowering solutions for individuals facing their own relationship challenges. I am also the former President of the Ottawa Chapter of the OAFM.

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