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Today's Date
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Please indicate what this intake is for:
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Mediation
Mediation-Arbitration
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)?
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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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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Annual Income
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OK to call work?
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Yes
No
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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Other Party's Annual Income
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Do you have interest in reconciliation with this person?
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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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Who made the decision to end the relationship?
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Tell us one positive thing about the other party
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Please provide a brief history of your marriage / relationship
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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.
Has there been a Section 30 Assessment?
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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
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
What are the issues that you want to discuss in mediation?
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Why are these issues important to you?
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Do you have any concerns about being in the same room with your former partner?
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What do you consider to be the greatest obstacle in reaching an agreement in mediation?
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Indicate the reasons that best explain your reasons for separating
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Physical abuse / violence
Threats
Drug / alcohol abuse
Mental illness
Infidelity
Poor communication
Emotional abuse
Incompatibility
Great deal of conflict
Taking advantage of the other person
Any other reasons that would best explain your reasons for separating?
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
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
Is there anything else you want us to know?
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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 purposes?
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Yes
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.
Have you read, completed and signed the Family Agreement to Mediate?
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Yes
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