New Meditation Clients NEW MEDIATION CLIENT INFORMATION FORM Name INSTRUCTIONS: Please fill this out prior to your initial appointment with Dr. Winder. Each party should fill this out by themselves. This form is ONLY for Dr. Winder to read so he can understand where each of you believes you are in the process. All information is optional. The more information you include here, the more productive your first mediation session will be. Name * Home Phone Cell Phone Other Phone OK to text (SMS)? Yes No E-mail Address * Is this email address private / secure? Yes No Maiden Name (if any) Date of Birth Current Address Nickname (if any) Place of Birth City, State, Zip Education: Highest level of education: Elementary School High School Some College BA / BS Graduate School Marriage: Date Place (City, State) Select Civil Religious Other Children Children from present marriage and other children living in household: Number of children Use this space to elaborate on any of the children’s special education, medical needs, or other pertinent information What best describes your children’s knowledge of your marital situation? they know nothing they know that something is happening they know that we are separating they think we are trying to work things out they know that we are definitely getting divorced Do you anticipate a dispute about custody of the children? Yes No Possibly SEPARATION/DIVORCE Who initiated the idea of separation or divorce? Self Partner What was the other person’s reaction? Are you presently living with your spouse? Yes No If no, when did you separate? (does not need to be exact date) If not living together, who initiated the separation? Self Partner Mutual Whose idea was it to start Divorce Mediation? Self Partner Mutual Who referred you to Dr. Winder? What best describes your current situation (Okay to check more than one): I want to reconcile & stay married I don’t know what I want I want a trial separation I want a legal separation followed by a divorce I want a divorce as quickly as possible Not clear if I want to get divorced Other Is there: Order of Protection or Restraining Order? Police File? CPS File? Other legal actions in force or pending? Indicate below the names and approximate date of last contact you had with: A marriage counselor or therapist who both you and partner saw: An individual therapist who you have seen or presently see: An attorney who you consulted about separation or divorce: Any other professional involved in your marriage / separation / divorce process: EMPLOYMENT INFORMATION Your occupation Job Title Name of Employer Work Address How Long at present job? How Long at present job? Other regular income Source Does your employer provide? Medical Insurance Life Insurance Auto Pension Savings Plan Stock Rights 401(k) Plan Other FAMILY FINANCES Do you own any of the following: House/Apartment Vacation Home Boat Antiques Collectibles Other Property of Value Business (describe) Cars (describe) Bank Accounts: Checking Savings Investments Stocks Bonds Mutual Funds Other invesments Retirement: IRA 401(k)/403(b) Oher Please list any major debts: Household finances have been previously handled by: Self Partner Mutual HEALTH INSURANCE Name of Plan Coverage is provided by: Your employer Yourself Partner’s employer Partner Your ID # Does insurance also cover your children? Yes No PRIOR MARRIAGES List below any prior marriages and indicate if there are any children, their ages, and who they live with. Please describe any financial arrangements between you and your former spouse: PRESENT SITUATION Please provide a brief history of your current marriage/relationship: What are the issues that you want to discuss in mediation? Do you have any concerns about being in the same room with your partner/ former partner What do you consider to be the greatest obstacle in reaching an agreement in mediation? Indicate the reasons that best explain why you are separating Poor Communication Threats Emotional abuse Drugs/alcohol abuse Incompatibility Mental illness Great deal of conflict Infidelity Physical abuse /violence Grown apart Other (describe below) Other Reasons Do you have any disabilities or other special circumstances / needs you would like Dr. Winder to know about? ANYTHING ELSE? Are there any other facts or circumstances that are relevant to your seeking mediation at this time, or anything else you think would be helpful for Dr. Winder to know about your situation?
