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 Birth Residing With
    child 1
    child 2
    child 3

    Are you currently paying support for these children?YesNo

      Full Name Date of Birth Residing 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