Intake Form for Third Party Screening

Today's Date

Date of Proposed Arbitration

Name of Arbitrator

First

Last

Age

What pronoun/s do you use (e.g., She/Her, He/Him, They/Them)?

Name of Other Party

First

Last

Occupation

Annual Income

Full Home Mailing Address

Phone (Primary)

Your email – please provide a non confidential email address that we can use to communicate with you and the other party together:

What is your first language?

Other party’s occupation

Other party’s income

Are there children of this relationship?

Yes
No

Has there been a Section 30 Assessment?

Yes
No

Has the Arbitration Agreement been signed?

Yes
No

Are there any court orders?

Yes
No

Are there any current agreements?

Yes
No

Do you have a lawyer?

Yes
No

Does the other party have a lawyer?

Yes
No

What are the issues for arbitration? (Explain)

Has there ever been a no-contact order between you and the other party (peace bond, restraining order, etc.)

Yes
No

Has there ever been a police file involving you and the other party?*

Yes
No

Has there ever been a CAS (Children’s Aid Society) file opened involving you or the other party?

Yes
No

Have any of the following concerns been raised in public document (eg/court file, court order, etc)? Please check all that apply:

Physical abuse / violence
Drugs / alcohol abuse
Mental illness
None of the above

Do you or the other party have any disabilities that you want us to know about?

Is there anything else you would want us to know about you or the other party before we meet you for your confidential meeting?

Cloud Storage

I consent to the use of “the cloud” for file storage purposes.

We acknowledge that High Park Mediation Inc. uses Google Workspace for the storage of information relating to your case.

Consent to use of Google Workspace for file sharing

I consent to the use of Google Workspace for file sharing purposes.

Consent to the Terms of Online Dispute Resolution

I agree to the privacy policy.I have read and agree with the Terms of Online Dispute Resolution.

been court order

Consent to Third Party Screening

I have signed the Consent to Third Party Screening (found separately on the website) and submitted it online.