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If you have any concerns about signing this form, if you do not understand what it means, or should you be concerned about any potential consequences of signing we urge you to get legal advice before doing so.

All parties must return signed copies of this form along with their applications for mediation in order for mediation to proceed.

Application - Client Data Form

Preferred Means of Communication
Do you have a prenup?
Living in same residence
Sig. Relationship with other adult
Obtained Legal Advice
Started Legal Procedings
Do you have children from this relationship?
Are there court/restraining orders against you?
Are there court/restraining orders against the other party?
Is there a police file?
Are there any disabilities/illness/addictions you wish to let me know about?
Issues to resolve

Non-Disclosure Agreement 


I, the client, agree/acknowledge:

Any and all information gathered in private conversations with the mediator, mediation interns and any observers (including intake interviews) is confidential except for situations where the mediator is ordered or required (e.g. information about a potential child protection issue) by law to disclose this information or where the disclosure of information suggests an actual or potential threat to human life or safety.

Should mediation proceed it shall be without prejudice meaning that any information disclosed of which I was previously unaware is inadmissible in any proceedings against the other party(ies) and that it cannot be disclosed to an arbitrator, tribunal or judge.

I will not issue a summons for Suzanne Winlove-Smith, the mediator, mediation interns and/or any observers to appear in any proceeding against the other party(ies) to disclose to an arbitrator, tribunal or judge any information, obtained from the other party(ies) in mediation intake, mediation , or private conversation, nor will I attempt to make Suzanne Winlove-Smith, the mediator, mediation interns and/or any observers disclose to me or anyone on my behalf any such information.  Should I obtain this or any inadmissible information (see paragraph #2) by any other means it may still not be used in any proceedings.

I will not issue a summons for the mediation records for any such proceedings.

I acknowledge that I have been strongly advised to seek independent legal advice on all matters in dispute and that this legal advice is important in understanding my rights and responsibilities.

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