Inttake_R | The Clean Divorce

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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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