Intake Form

Complete the Intake Form found below to the best of your ability. The information you provide us will be completely confidential and will NOT be disclosed to the other party. We use the information to identify the issues to be discussed and to asses whether mediation is right for you.

Once you have completed and submitted the Intake Form, please allow up to 2 days for us to review and respond. If you have any questions or concerns, please do not hesitate to contact us.

The Intake Form will take approximately 20 minutes to complete.

Intake Form

Please note: the Intake Form will not save your progress. Please do not navigate from this page until all sections of the Intake Form have been completed and you have clicked submit at the end of the form.

- Step 1 of 5

YOUR INFORMATION

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Email *

Lawyers Name

Issues to be Mediated (Please check all that apply)

Parenting Plan
Child Support
Property Issues
Spousal Support
Other

Do you have an existing order or Agreement or Court Order?

Have you attended a Mandatory Information Program (MIP)?

OTHER PARTY INFORMATION

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone

Lawyers Name

Duty Counsel/Advice Counsel Name

Layout

Employer or Source of Income

Annual Income

CHILDREN INFORMATION

Child One

First

Last

Layout

Age

Date of Birth

Resides With

Male/Female

Male
Female

Child Two

First

Last

Layout (copy)

Age

Date of Birth

Resides With

Male/Female

Male
Female

Child Three

First

Last

Layout (copy) (copy)

Age

Date of Birth

Resides With

Male/Female

Male
Female

Child Four

First

Last

Layout (copy) (copy) (copy)

Age

Date of Birth

Resides With

Male/Female

Male
Female

Date that you and the other party started living together:

Date of marriage:

Date of seperation:

Do you both still live in the same house / apartment now?

Do you or your former partner have a substance abuse problem (i.e... alcohol, drugs, prescription drugs)

Please describe:

Do you or your former partner suffer from mental health problems that require either of you to take prescription drugs?

Please describe:

Have you or your former partner ever been arrested or convicted for committing a violent crime?

Please describe:

At the present time, do you or your former partner own a gun?

Are you fearful of your former partner for any reason?

Please describe:

Have you ever called the police, requested a protection from abuse order, or sought help for yourself as a result of abuse by your former partner?

Please describe:

Has your former partner ever threatened to hurt you or your children in any way?

Do you have ANY concerns of something happening during Mediation that may cause any future aggression or violence within the family?

Please describe:

Has your former partner ever threatened to deny you access to your children?

Please describe:

Do you have any concerns about the children's emotional or physical safety?

Please describe:

Have you or your former partner ever had contact with the Children's Aid Society?

Please describe:

Is there currently an open Children's Aid Society file?

When you and your former partner were living together and when you became involved in disagreements or conflicts, how well did you stand up and state your position, compared to your former partner?

Better
Equally well
Less well

At the present time, if you and your former partner become involved in disagreements or conflicts, how well can you stand up and state your position, compared to your former partner?

Better
Equally well
Less well

Are there any conditions preventing contact between you and your former partner, either direct or indirect? If yes, please select which of the following apply:

Conditions of Bail
Peace Bond
Restraining Order
Terms of Probation
Other

If you selected other, please describe:

Is there any reason why you would feel uncomfortable being in the same room and/or mediating with the other party?

What is your current employment status?

Employed full time
Employed part time
Full time home-maker
Student
Not employed

If you checked "Not employed", please select one of the following:

Unemployment Insurance
Ontario Works
Disability
Retired
Other

What is your total gross income from all sources?

Are you currently in a new marriage/common-law relationship?

If yes, since when?

Name of current partner:

First

Last

Do you have other children not mentioned above?

If yes, please list below:

Please provide the following information for each child: Name, sex, date of birth, age, and who they are currently living with.

Please provide (with a simple explanation) what you perceive as the issues for mediation:

Have any legal proceedings been commenced in Court?

Court File Number:

Next Court Date:

Is there a current court order of temporary court order?

Have you signed a Separation Agreement with your former partner?

If you answered yes, when was it signed?

Did you sign a cohabitation, pre-nuptual, or any other domestic agreement that set out what would happen if you separated?

Are you entering into mediation voluntarily?

If no, please explain:

Why have you chosen mediation to resolve your Family Law Matter?

Which of the following best describes where you live currently?

House (owned) with a mortgage
House (owned) without a mortgage
House rented privately
House rented from Ontario Housing
Live with a friend/relative, no rent
Live with a friend/relative, with rent
Other

If other, please describe:

Are you currently living in the matrimonial home?

A “matrimonial home” has a specific definition in Ontario law. It is the house that a married couple lives in at the time of separation.

At the time of your final separation, who moved out of the family home?

You
Your Partner
Both
Neither

Who made the decision to separate?

You
Partner
Both

Couples who separate/divorce do so for a number of reasons; please state 3 reasons which best explain why you and your partner separate:

Are you and your partner living in separate residences at this time?

When did you being living separately?

Please explain the current living arrangements:

Have the police ever been called because of conflict in your family?

Have there ever been criminal charges laid as a result of this involvement?

Is there anything else that you would like to tell us?

Please allow up to 2 business days for us to review your Intake Form. Once we have reviewed your Intake Form we will contact you to make further arrangements.