Mediation Intake Form First Name Last Name Any other names you have used Your Phone Number Your Email Your Date of Birth Your Address Do you have a lawyer? Other Party's First Name Other Party's Last Name Any other names other party has used Other Party's Phone Number Other Party's Email Other Party's Date of Birth Other Party's Address Does the other party have a lawyer? Married or common-law Married Common-law Neither Date of marriage or start of cohabitation Currently living together? Yes No Date of separation Reasons for separation Children of the relationship We have no children. We have one or more dependent children together. We have children together but none are dependent on either of us. Does any child have a disability? What issues need to be resolved? Decision-making for the children Parenting time for the children Child support Spousal support Division of matrimonial property Sale of matrimonial home Domestic violence or other criminal charges Other Any other information about your case Your employment Your average annual salary Other party's employment Other party's average annual salary Is there an active family court proceeding? Yes No Details about your court proceeding Acknowledgement I understand that information provided to Eaton Law (by me or any other party in connection with this proposed mediation) is confidential and may not be used at court. I agree that no person involved with Eaton Law shall be a compellable witness in any current or future legal proceedings in regards to this file. I understand that mediation is a voluntary process and that the mediator is a neutral facilitator who is present to help the parties come to an agreement that is acceptable to them. The mediator will not provide legal advice to either of the parties. I also understand that no client-mediator or client-solicitor relationship is formed between Eaton Law or its respective agents until an agreement for services is signed. I understand that there will be a fee for mediation, which will be outlined in a service agreement that I will review before the commencement of mediation services. Send