Client Intake Form – Part I Basic Information


  • Is Mediation Right For You?  We encourage you to ask your self these two questions.
    First, can I work with my spouse cooperatively, with the assistance of a mediator, and negotiate an agreement and save the costly expenses of contested divorce litigation? 
    , has my contested divorce litigation stalled or gone out of control and can I work with my spouse cooperatively with the assistance of a mediator.  If you answered yes to either of these questions it may be time to mediate your divorce and negotiate an agreement directly with your spouse and save the ongoing costly expenses of contested divorce litigation!
  • Notice:  At the Initial Free Consultation You, Your Spouse and the Mediator will complete and submit the below Intake form together.  Your mediator, within 24 hours of that initial consultation, will then prepare a Complementary beginning draft of you mediated agreement.  If you decide to retain us as your mediator we will continue adding onto that agreement until it is complete.  If you choose not to retain us, keep the beginning draft on us and use it as you like.

Client Intake Form - Part I Basic Information


Today's Date:

Email of person completing this form (required)


Date of the Parties Marriage:
City/Town/Village where Parties Marriage
State of the Parties Marriage
Type of ceremony


Number of Children of the Marriage including adopted children

Wife's Information:

Wife''s Email (required):

Wife's Name:

Wife's Address1:

Wife's Address2:

Wife's City:

Wife's State:

Wife's Zip Code:

Wife's County:

Wife's Phone:

Wifes Date of Birth:

Wifes Place of Birth:

Wife's Social Security Number:

Husband's Information:

Husband's Email (required)

Husband's Name

Husband's Address1

Husband's Address2

Husband's City

Husband's State

Husband's Zip Code

Husband's County

Husband's Phone

Husbands's Date of Birth:

Husband's Place of Birth

Husband's Social Security Number

Fee Arangements

Type of Divorce Mediation Interested In - On-Line $1,250.00 or In Office $1,650.00.
Discount, if any.