PERSONAL DATA AND INFORMATION

1. Name
Home Address
Street
City

state
Zip

Work Phone
Home Phone

Best way to contact you:
E-mail

2. Age

3.Date of Marriage
Date of Separation

 Full Name Date of BirthResiding With
child 1
child 2
child 3

Are you currently paying support for these children?YesNo

 Full Name Date of BirthResiding With
child 1
child 2
child 3

Are you currently paying support for these children? YesNo

6.Other than your children and/or your spouse, are there any people living with you now? YesNo

If yes, list their names and their relationship to you

7.Are you employed? YesNo

If yes, give name of employer:

Address of employer

8. Highest level of education attained

Field(s) of study

9.Do you have an interest in reconciliation? YesNo

As far as you know, does your spouse?YesNo

10.Are you presently seeing a counselor or therapist? YesNo

If yes, IndividualJointFamily

Please list name of counselor or therapist

11. Have you previously seen a counselor or therapist?YesNo

If yes, IndividualJointFamily

12.Do you anticipate a dispute about custody of the children?YesNo

13. Do you presently have an attorney?YesNo

If yes,

Name

Address

Phone

14. Are there joint bank accounts to which your spouse has access? YesNo

15. Does your spouse have credit cards you are responsible for? YesNo

16. Do you have a will?YesNo

17.How did you learn about Diana Mercer and Peace Talks Mediation Services?

(Give name and relationship, where applicable)

18.Security Code