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Today's Date
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Referred By
Has a court file been started by you or the other party?
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Yes
No
Court File No.
Status of File
Name
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First
Last
Age
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What pronoun/s do you use (e.g., She/Her, He/Him, They/Them)?
Relationship to Child(ren)
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Street Address
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Address Line 2 (if applicable)
City
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Province / Territory / State / Region
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Country
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Phone (Primary)
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Phone (secondary/work)
OK to call work?
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Yes
No
Your email – please provide a non confidential email address that we can use to communicate with you and the other party together:
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Employer / Job
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What is your total annual income from all sources?
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Your lawyer, if any
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Your lawyer's email, if any
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Date of marriage / cohabitation?
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Date of separation?
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What is your first language?
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Your lawyer?
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Your lawyer's email address?
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Other Party's Name
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First
Last
Other Party's Age
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Other Party's Phone Number
Other Party's Employer / Job
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What is the Other Party's total annual income from all sources?
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Are there any legal reasons that prevent you from communicating directly or indirectly (restraining order / peace bond)?
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Name all persons with whom you reside (including child(ren), partners, roomers, relatives, caregivers, etc.):
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Are there children from this marriage / relationship?
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Yes
No
If yes, please list the childrens' names, ages, and who they are currently living with.
Do you have children from any other relationship?
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Yes
No
If yes, please list the childrens' names, ages, and who they are currently living with.
What are the issues that need to be decided in arbitration?
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Why are these issues important to you?
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Have you tried mediation or another settlement process?
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Yes
No
If YES, what issues have been resolved already?
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Are there any urgent matters?
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Yes
No
If YES, briefly explain the urgent issues:
Do you have any concerns about being in the same room with your former partner?
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Are there any Agreements, Parenting Plans, or Court Orders?
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Yes
No
Has there been a Hear the Child/Voice of the Child Report done?
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Yes
No
If NO to the above, is either party requesting one?
Yes
No
Do you have any disabilities you would like us to know about?
Are you living in the same house as the other person?
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Yes
No
What are the disputes between you and the other parent?
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How effectively do you and the other parent communicate about the children?
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What are your significant concerns about your co-parenting relationship with the other parent?
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What do you and the other parent do well as parents?
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Are there any no-contact orders?
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Yes
No
Do you have concerns about:
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Physical abuse / violence
Mental health
Verbal abuse
Other
Has there been a Section 30 Assessment?
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Yes
No
Is there a history of Children's Aid Society (CAS) involvement?
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Yes
No
Is there a history of police involvement?
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Yes
No
Is there anything else you would like the Arbitrator to know?
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Do you have your own computer that is private, password-protected, has a camera and a microphone? Cell phones can be used if no access to computer or laptop.
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Yes
No
Do you have a private place where you can have an online meeting without anyone else hearing or watching you?
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Yes
No
Third Party Screening
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I consent
If you are seeking arbitration, rather than mediation-arbitration, we will refer both parties to a Third Party Screener who will meet with both, separately and confidentially, and provide us with a Report in confidence, before we can agree to proceed.
High Park Mediation Inc. uses Google Workspace for the storage of information relating to your case. Do you consent to the use of such Cloud Storage?
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Yes, I consent to the use of Google Workplace Cloud Storage.
High Park Mediation Inc. uses Google Workspace for sharing files among clients, counsel and the FDR professional. Do you consent to the use of Google Workspace for file storage and sharing purposes?
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Yes, I consent to the use of Google Worksplace for file storage and sharing purposes.
Have you read and do you agree to our Privacy Policy?
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Yes
The Privacy Policy can he read
here.
Have you read and do you agree to our Use of Technology Information & Consent Policy?
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Yes
The Use of Technology Information & Consent Policy can be read
here.
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