CONFIDENTIAL AND PRIVILEGED
Client Goals and Concerns Questionnaire
The main aim of this questionnaire is to help everyone involved in the mediation to prepare, on the basis that mediation requires an understanding of everyone’s perspective of the dispute and helps everyone to focus their attention on the practical and emotional challenges that lie ahead.
The answers to these questionnaires are not shared with anyone else.
Please complete and return your answers to the mediator by email before your pre-mediation
Thank you very much.
1. What are your most important goals or hopes? Why are they important to you?
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2. What are your most important worries, concerns, or fears? Why are they important to you?
3. What do you think your spouse's most important goals or hopes are? Why do you think these are important to your spouse?
4. What do you think your spouse's most important worries, concerns, or fears are? Why do you think these are important to your spouse?
5. What are your most important goals or hopes for your children?
6. What are your most important worries/ concerns/ fears for your children?
9. What does conflict typically look like between you and your spouse? (e.g., silent withdrawal, angry outbursts, calm discussion, changes of mind, giving in, getting stuck)
8. What are your concerns/ fears/ worries and hopes/ beliefs if this matter were to go to court?
7. What are your concerns/ fears/ worries and hopes/ beliefs about using this mediation process?
10. Is there a pattern you would like to avoid or change during this process? (e.g., always giving in, getting lost in the details, drawing early lines in the sand)
11. How can I best support you during this process? (What would your closest or wisest friend or family member worry about for you in this process?)
12. If you were looking back three years from now and reflecting on the mediation process: What would have had to happen to cause you to be highly dissatisfied with the mediation process and not recommend it to anyone? Not to recommend me as a mediator?
14. If you were looking back three years from now and reflecting on the mediation process: What would have had to happen for you to feel highly satisfied and recommend the mediation process to anyone you cared about? To recommend me as a mediator to anyone you cared about?
13. If you were looking back three years from now and reflecting on the mediation process: If this process were unsuccessful, how would you have contributed to its failure?
15. If you were looking back three years from now and reflecting on the mediation process: If this process were successful, how would you have contributed to its success?
16. Do you have any concerns about your emotional well-being, physical health, mental health, capacity to make decisions, anger management, alcohol, or drug use?
17. Do you have any concerns about your spouse's emotional well-being, physical health, mental health, capacity to make decisions, anger management, alcohol, or drug use?
18. What would you like to achieve in mediation? What is it about these things that make them important for you to achieve?
19. What do you believe the other person involved would like to achieve? Why do you believe these things are important to them?
20. What do you believe is preventing you both from achieving these things?
21. What would you like the other person to hear from you?
22. What would you like to hear from them?
23. Briefly explain how you believe the current dispute has arisen.
24. If all of you cannot reach a successful outcome in mediation, what will this mean for you?
25. If you cannot agree, what do you fear will happen?
26. It is very important to a child's development that their parents can set good examples for their children to follow. What are some of the things you could do to improve your situation with the other parent?
27. How would you like your future to look and how do you want to feel about your past and your journey?
28. Is there anything else you think it would be helpful for me to know?
