PERSONAL DATA AND INFORMATION 1. Name Last First Middle (maiden) Home Address Street City state ArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllonoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandRhode IslandSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Work Phone Home Phone Best way to contact you: By phoneBy mail E-mail 2. Age 3.Date of Marriage Date of Separation 4.Children of Current Marriage Full Name Date of Birth Residing With child 1 child 2 child 3 Are you currently paying support for these children?YesNo 5.Children of Previous Marriage/Relationship? 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 Name: Relationship: 7.Are you employed? YesNo If yes, give name of employer: Address of employer Street: City: State: Zip: Job Title Nature of Job Date Hired Current Salary 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 Δ
