Intake Form | Sound Mediations

Sound Mediations does not mediate family law disputes unless the parties are referred by an attorney.

Is the matter:*

A Family Dispute
Another Civil Dispute

Are any parties represented by an attorney?*

Yes
No

Plaintiff

Name

First Last

Attorney's Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Petitioner’s side:

Defendant

Name

First Last

Attorney's Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Respondent’s side:

Other Information

Has a lawsuit been filed?*

Yes
No

Court:

Cause Number:

Significant issues to address during mediation:

Are there any concerns about having the parties in the same room at any point during mediation?

Yes
No

Are there any protection orders?

Yes
No

Petitioner

Name

First Last

Attorney's Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Petitioner’s side:

Respondent

Name

First Last

Attorney's Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Respondent’s side:

Other Information

Has a lawsuit been filed?*

Yes
No

Court:

Cause Number:

Significant issues to address during mediation:

Are there any concerns about having the parties in the same room at any point during mediation?

Yes
No

Are there any protection orders?

Yes
No

Petitioner

Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Petitioner’s side:

Respondent

Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Respondent’s side:

Other Information

Court where petition has been filed:

Cause number:

Date of marriage:

Place of marriage:

Date of separation:

Does either party have a desire to reconcile?

Yes
No

Are there any concerns about having the parties in the same room at any point during mediation?

Yes
No

Are there any protection orders?

Yes
No

Do the parties need to mediate distribution of property, including debts?

Yes
No

Consider: real estate, cash and bank accounts, investment accounts, life insurance, vehicles, retirement accounts, and other assets.

Petitioner’s separate property (if not in Petitioner’s possession, please indicate) with value:

Community property in Petitioner’s possession with value:

Respondent’s separate property (if not in Respondent’s possession, please indicate) with value:

Community property in Respondent’s possession with value:

Describe any disputes over character of property (community or separate):

Debts in Petitioner’s name only with balance due, monthly payment amount, and interest rate:

Debts in Respondent’s name only with balance due, monthly payment amount, and interest rate:

Debts in both parties’ names with balance due, monthly payment amount, and interest rate:

Do the parties need to mediate spousal maintenance?

Yes
No

Length of marriate:

Petitioner’s highest education:

Respondent’s highest education:

Petitioner’s employment during marriage:

Petitioner’s average monthly gross income during marriage:

Respondent’s employment during marriage:

Respondent’s average monthly gross income during marriage:

Petitioner’s current employment:

Petitioner’s current gross monthly income:

Respondent’s current employment:

Respondent’s current gross monthly income:

Petitioner’s health insurance: through employer? exchange? none?

Respondent’s health insurance: through employer? exchange? none?

Petitioner’s significant expenses:

Respondent’s significant expenses:

Do the parties need to mediate a parenting plan?

Yes
No

Have both parties completed all required parenting classes?

Yes
No

Name, gender, date of birth, and living arrangements of each child of this marriage:

Is either party currently pregnant?

Yes
No

Name, gender, date of birth, and living arrangements of additional children of Petitioner:

Name, gender, date of birth, and living arrangements of additional children of Respondent:

Where does each child attend school?

Have any temporary orders been entered?

Yes
No

Was a GAL appointed?

Yes
No

Have any assessments been done of either parent or any child?

Yes
No

Does either party request a substantial deviation from a joint custody arrangement?

Yes
No

Does either parent have concerns about overnight visits with the other parent?

Yes
No

Do the parties need to mediate child support?

Yes
No

Petitioner’s current employment:

Petitioner’s current gross monthly income:

Respondent’s current employment:

Respondent’s current gross monthly income:

Is health insurance available through Petitioner’s employer?

Yes
No

Is health insurance available through Respondent’s employer?

Yes
No

Does any child have health care costs that are not paid by insurance?

Yes
No

Is day care needed?

Yes
No

Are there any other special expenses related to any child?

Yes
No

Employment and gross monthly income of other adults in Petitioner’s household:

Employment and gross monthly income of other adults in Respondent’s household:

Plaintiff

Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Plaintiff’s side:

Defendant

Name

First Last

Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Contact Email

Name all people who will attend mediation on the Defendant’s side:

Other Information

Has a lawsuit been filed?

Yes
No

Court:

Cause number:

Have both parties agreed to mediation?

Yes
No

Are there any concerns about having the parties in the same room at any point during mediation?

Yes
No

Significant issues to address during mediation:

Please provide your version of significant events to date:

Would your ideal resolution include payment of money from one party to another?

Yes
No

Who should pay, and how much?

Would your ideal resolution include other actions taken by either party?

Yes
No

Please describe:

Provide any suggestions you have for a possible compromise:

Is there any other information you think would be helpful for the mediator to know?

Mediation Intake Form

Sound Mediations does not mediate family law disputes unless the parties are referred by an attorney.

Plaintiff

Defendant

Other Information

Petitioner

Respondent

Other Information

Petitioner

Respondent

Other Information

Plaintiff

Defendant

Other Information