Parenting Coordination Intake Form

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Today's Date

Referred By

Name

First

Last

Age

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

Relationship to Child(ren)

Street Address

Address Line 2 (if applicable)

City

Province / Territory / State / Region

Country

Phone (Primary)

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

Employer / Job

What is your total annual income from all sources?

Your lawyer, if any

Your lawyer's email, if any

Date of marriage / cohabitation?

Date of separation?

What is your first language?

Your lawyer?

Your lawyer's email address?

Other Party's Name

First

Last

Other Party's Age

Other Party's Phone Number

Other Party's Employer / Job

What is the Other Party's total annual income from all sources?

Name all persons with whom you reside (including child(ren), partners, roomers, relatives, caregivers, etc.):

Are there children from this marriage / relationship?

If yes, please list the childrens' names, ages, and who they are currently living with.

Do you have children from any other relationship?

If yes, please list the childrens' names, ages, and who they are currently living with.

Has a court file been started by you or the other party?

Are there any Agreements, Parenting Plans, or Court Orders?

Has there been a Hear the Child/Voice of the Child Report done?

What are the disputes between you and the other parent?

How effectively do you and the other parent communicate about the children?

What are your significant concerns about your co-parenting relationship with the other parent?

What do you and the other parent do well as parents?

Are there any no-contact orders?

Do you have concerns about:

Physical abuse / violence
Mental health
Verbal abuse
Other

Has there been a Section 30 Assessment?

Is there a history of Children's Aid Society (CAS) involvement?

Is there a history of police involvement?

Is there anything else you would like the Parenting Coordinator to know?

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.

Do you have a private place where you can have an online meeting without anyone else hearing or watching you?

Is there anything else you want us to know?

Agreement for Confidential Intake Meeting to Assess Suitability for Parenting Coordination

I agree

PRINCIPLES

1. The above-named parties each wish to retain High Park Mediation Inc. for the purpose of conducting a Parenting Coordination Intake Meeting. The purpose of this meeting is to enable the parties and the Parenting Coordinator to assess whether the matter is appropriate for Parenting Coordination and that it can be designed in a way that meets the needs and goals of each party and their child/children: and to ensure the parties understand the implications of the process should it be appropriate in their circumstances. The intake forms provided by the parties before this meeting form part of the Intake Meeting process.

2. Should this meeting be conducted using online technology, each party will read the Terms of Online Dispute Resolution before their meeting.

PRIVATE, CONFIDENTIAL AND WITHOUT PREJUDICE

3. All information and documents provided by each party shall remain confidential between that party and the Parenting Coordinator. All information arising from the Intake Meeting process, including the Parenting Coordinator’s notes, the intake form, and the file, shall be used only by the Parenting Coordinator for the purpose of assessing whether Parenting Coordination is an appropriate process for the parties and the family.

4. Neither party nor the Parenting Coordinator shall record any part of the Intake Meeting Process.

5. The Parenting Coordinator may, solely at their discretion, release some of the information provided by a party as part of the Intake Meeting process to that party’s lawyer or other professional retained by that party if doing so would, in the opinion of the Parenting Coordinator, assist them in assessing suitability of the matter for Parenting Coordination. No information arising from the Intake Meeting process shall be otherwise disclosed to any person for any purpose except as required by law. Such exceptions may include:

• Reporting a child in need of protection in accordance with section 125 of the Child, Youth and Family Services Act; or

• Where the Parenting Coordinator believes on reasonable grounds that there is an imminent risk, to an identifiable person or group, of death or serious bodily or psychological harm, they may disclose such confidential information that is required in the circumstances to prevent such death or harm.

• Where the Parenting Coordinator is ordered by a court to provide evidence.

6. Neither party will Summons the Parenting Coordinator to provide evidence with respect to the Intake Meeting Process in any proceeding, nor will either seek production of any documents that were provided for or prepared in connection with the Intake Meeting Process (unless they are otherwise discoverable).

RIGHT TO WITHDRAW

7. Each party has the right to withdraw from the Intake Meeting Process. The Parenting Coordinator has the right to terminate the Screening Process in their discretion.

FEES

8. The fee for the Intake Meeting is set out on the High Park Mediation website and is updated from time to time. All fees for Intake Meetings shall be paid by each party, in advance of the Meeting, by online payment using debit, credit or e-transfer.

WAIVER OF LIABILITY

9. The parties waive any claim or right of action against High Park Mediation Inc. or the Parenting Coordinator for any matters arising out of the in good faith services provided pursuant to this Agreement.

During the intake meeting, the following types of questions may be asked:

I agree

1. Have there been any recent major life events – positive and negative (i.e. loss, accident, change of employment, birth of child(ren), marriage, etc.)?

2. How do you think the conflict between you and the other parent affects the child(ren)?

3. What do you think would decrease the conflict between you and the other parent?

4. What are the reasons why you and the other parent cannot resolve disputes yourself?

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?

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?

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?

The Privacy Policy can he read here.

Have you read and do you agree to our Use of Technology Information & Consent Policy?

The Use of Technology Information & Consent Policy can be read here.