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Contact us regarding a Family Matter:
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Type of Family Matter: |
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Name: |
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Phone #: |
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Email Address: |
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Street Address: |
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City: |
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State/ZIP: |
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Is this the marital residence?
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No
Yes
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If not, what is the marital address?
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Street Address: |
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City: |
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State/ZIP: |
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Date of Marriage: |
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Place of Marriage
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City: |
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State/ZIP: |
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Children of Current Marriage:
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Children of Previous Marriage(s):
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Are you paying spousal support to your current spouse?
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No
Yes
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Are you receiving spousal support from your current spouse?
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No
Yes
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Are you paying spousal support to a previous spouse?
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No
Yes
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Are you receiving spousal support from a previous spouse?
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No
Yes
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Are you and your spouse currently living together?
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No
Yes
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If not, Date of Seperation: |
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Names of persons living with you (other than previously listed children):
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Are you presently employed?
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No
Yes
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How Long?
Job Title:
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Do you have interest in reconciliation?
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No
Yes
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As far as you know, does your spouse?
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No
Yes
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Are you presently seeing a marriage counselor or therapist?
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No
Yes
No, but I have in the past.
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Do you anticipate a dispute over custody of children?
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No
Yes
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Have you hired an attorney for this matter?
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No
Yes
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Has this matter been filed with any court?
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Are there joint bank accounts?
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No
Yes
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Are there joint credit cards?
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No
Yes
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Are there joint debt accounts (mortgage, auto loans, etc.)?
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No
Yes
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Do you have a will?
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No
Yes
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What do you estimate your total marital debt to be? |
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What do you estimate your total marital assets to be? |
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What agreements have you and your spouse already reached?
(division of property, house, cars, parenting plan, spousal support, etc.) |
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Release of information to Consensus Meediation Services, LLC: |
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I release the above information to Consensus Conflict Management & Mediation Services, LLC
for the purposes of consultation and mediation in this matter should
I retain their services. I understand that this information will be
destroyed by Consensus Conflict Management & Mediation Services, LLC if I do not retain their
services within thirty (30) days of the date of submittal of this
information to them. I further understand that, in the event I do
retain the services of Consensus Conflict Management & Mediation Services, LLC, the
information provided above will be used as work product and in any
case, all information shall be considered private and confidential at
all times. Consensus Conflict Management & Mediation Services, LLC assures me that all
information provided to them by me or my co-party shall be destroyed
upon completion of mediation. I affirm that I am of lawful age and
authority to provide this information and enter this agreement.
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I accept these terms.
I decline these terms.
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