Mediation Intake Questionnaire — Custody, Visitation, and Support/Marital.Please complete this when you are asked, before your mediation appointment. This will help determine whether your case is appropriate for mediation.Thanks, SMS, LLC Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### What is your current work schedule? This is necessary to determine the best dates and times to have a mediation session. Do you have any information that you do not want shared with another party? * No All (email, telephone, and address) Address Email Telephone Are you interested in developing your issues through the mediation process? * Yes No Are you able to communicate with the other party on an equal basis during mediation sessions? * Yes No Maybe Are you able to speak up for yourself without intimidation or fear? * Yes No Maybe Are you able to communicate with the other person in a respectful manner, even regarding topics which you may not agree on? * Yes No Maybe Are you fearful of the other person or any reason? * Yes No Maybe Have they intentionally destroyed your property or the property of your children? * Yes No Maybe Have they ever threatened to hurt you in any way? * Yes No Maybe Have they ever used any form of physical violence against you? * Yes No Maybe Have you ever had to contact the police, requested a protective order, or sought help for yourself or your child(ren) as a result of abuse by the other person? * Yes No Are you fearful of retaliation of any kind by the other person, either during or following the mediation session(s). * Yes No Do you have any concerns that the other party would try to take, or keep, your child from you? * Yes No Possibly Do you have safety concerns for your child when they are in the care of the other parent? * Alcohol Abuse Illegal Drug Abuse Prescription Drug Abuse Physical Abuse Sexual Abuse Emotional Abuse Serious Neglect Mental/Behavioral Health Issues Lack of Supervision Other issue(s) None Has child protective services ever been involved with your family? * Yes No Is there a current safety plan in place for your family? Yes (Please provide DSS contact below) No I am unsure (Please provide DSS contact below) DSS Contact Name First Name Last Name DSS Phone (###) ### #### THE FOLLOWING QUESTIONS RELATE TO CHILD SUPPORT CASES ONLY Have you received, in the past 24 months, Temporary Assistance for Needy Families, also known as TANF? N/A No Yes Do you believe that you will abide by the agreement reached through the mediation process? N/A No Yes Do you believe that the other party will abide by the agreement? N/A No Yes Possibly Do you have any additional concerns about the mediation process that you would like to share at this time? Please use this text box to provide clarification on any question answered "yes" or "maybe/possibly" to. This information will be provided to the mediator only and not shared with any other party. If you wish to complete this over the phone, please contact SMS, LLC at 540-757-3252, By clicking "Submit" below, I understand that a mediator cannot and does not provide legal advice. * Yes No, I would not like to continue the mediation process. By clicking "Submit" below, I understand and agree that any mediated agreement may effect the rights of the parties, including me. * Yes No, I would not like to continue the mediation process. By clicking "Submit" below, I understand that each party, including me, has the right and opportunity to consult with independent legal counsel at anytime and is encouraged to do so. * Yes No, I would not like to continue the mediation process. By clicking "Submit" below, I understand that each party has the right, and is encouraged, to have any agreement reviewed by independent legal counsel prior to signing. By signing any agreement without such review, I understand that I am waiving that right. * Yes No, I would not like to continue the mediation process. By placing your name and clicking "Submit" below I agree: that I have reviewed all aspects of this submission; that I am signing this electronic submission the same as if it were a physical document; that the information which I have provided above is a true representation to the best of my understanding and belief. Please Sign Your Name. * Thank you!
