Formulaire d’information sur la médiation

Veuillez prendre quelques instants pour remplir ce formulaire d’information privé et confidentiel. Il s’agit de la première étape de la procédure de médiation confidentielle. La procédure ne peut commencer que lorsque nous avons reçu les formulaires d’information des deux parties. Les services de méditation sont disponibles en personne et à distance par le biais de la technologie pour tous les sites.

Une fois que nous aurons reçu les formulaires d’information des deux parties, le médiateur assigné à votre affaire vous contactera individuellement pour organiser vos réunions d’accueil confidentielles. Ces réunions sont gratuites. Au cours des réunions d’accueil, le médiateur évaluera si votre affaire se prête à la médiation. Certains cas peuvent ne pas se prêter à la médiation.

Si vous avez une date d’audience et/ou un numéro de dossier judiciaire, la médiation sur place vous sera proposée gratuitement pour les affaires qui peuvent être traitées en deux heures ou moins. Si vous n’avez pas de date d’audience et/ou si vous avez un numéro de dossier judiciaire, le ministère du Procureur général subventionne les frais de médiation familiale pour la médiation hors site. Ces frais sont facturés en fonction des revenus de chaque personne. Cliquez ici pour connaître le barème des frais.

Nous encourageons tous les clients à obtenir des conseils juridiques avant, pendant et après toute médiation.

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Today's Date *

Court Location: *

Referred To Mediation by:

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Are you in court today? *

Who is your mediator? *

Do you have a court order? *

Have you or the other party filed or been served with a Form 8A / Form 8 (Application), a Motion to Change (Form 15), or a court order in Family Court? * *

If yes, are you the Applicant or the Respondent? *

Applicant
Respondent
Neither

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What is your court file number?

When is your next court date?

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Has the judge ordered you to attend intakes or mediation? *

Yes
No
I Don't Know

Do you prefer virtual (Zoom) or in-person meetings? *

Virtual (Zoom)
In-Person

CLIENT INFORMATION

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Your Full Legal Name: *

Date of Birth *

Age: *

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Current Address: *

Apt/ Unit:

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City: *

Province

Postal Code:

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Phone (Primary) *

Phone (Alternative)

Email *

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Employer / Source of Income

Annual Income $ *

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Lawyer's Name:

Duty Counsel's Name:

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Language *

Do you require an interpreter?

Have you visited the Family Law Information Centre (FLIC)

Have you attended the Mandatory Information Program?

OTHER CLIENT DETAILS

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Other Party's Full Legal Name: *

Other Party Date of Birth

Other Party's Age:

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Other Party's Current Address:

Other party's Apt/ Unit:

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Other Party's City:

Other Party's Province

Other Party's Postal Code:

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Other Party Phone (Primary) *

Other Party's Phone (Alternative)

Other Party's Email *

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Other Party's Employer / Source of Income

Other Party's Annual Income $ *

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Other Party's Lawyer's Name:

Other Party's Duty Counsel's Name:

RELATIONSHIP INFORMATION

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How long did you date?

Years - Months

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Did you live together? *

Were you legally married? *

What is your date of separation?

Who made the decision to separate?

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Are you or have you completed marriage/couples counselling?

Do you have a signed separation agreement?

Have either of you left the family home?

Do you have any interest in reconciliation?

Do you have a prenuptial / marriage contract?

List any reason which contributed to your separation:

CHILDREN:

Are there children in the relationship? *

1. Child Name:

1. Date Of Birth

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2. Child Name:

2. Date Of Birth

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3. Child Name:

3. Date Of Birth

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4. Child Name:

4. Date Of Birth

Add if required:

Are you in a new relationship?

Do you have children from another relationship?

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1b. Child Name:

1b. Date of Birth

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2b. Child Name:

2b. Date of Birth

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3b. Child Name:

3b. Date of Birth

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4b. Child Name:

4b. Date of Birth

Add if required:

MEDIATION INTEREST:

Are you entering into mediation voluntarily? *

Do you have any concerns about mediating with your former partner? *

If yes, please explain:

Issues to be mediated (check all that apply):

Parental Decision Making
Extraordinary Expenses
Property / Financial Issues
Access / Parenting Time
Spousal / Parent Support
Travel
Child Support
Mobility
Other

LEGAL AND COURT PROCEEDINGS

Has there been a court case in the past between you and the other party? *

Have you requested a protection order due to abuse? *

Has the other party been convicted of any domestic abuse charges? *

EVENTS SIX MONTHS BEFORE AND SIX MONTHS AFTER SEPERATION:

Has your former partner done any of the following hurtful acts or behaviours? Please answer YES or NO for each question. If YES, please check when (before and/or after separating) and how often.

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Threatened to come after you if you tried to leave? *

When did they threaten to come after you if you tried to leave?

During last six months prior to separation
Since you emotionally separated

How Often did they Threaten to come after you if you tried to leave??

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Threatened to hurt or kill you? *

When did they threaten to hurt or kill you?

During last six months prior to separation
Since you emotionally separated

How Often did they threaten to hurt or kill you?

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Showed anger by yelling, throwing or breaking things, pounding walls or tables? *

When did they show anger by yelling, throwing or breaking things, pounding walls or tables?

During last six months prior to separation
Since you emotionally separated

How Often did they show anger by yelling, throwing or breaking things, pounding walls or tables?

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Put you down, called you names, swore at you, insulted you in public? *

When did they put you down, called you names, swore at you, insulted you in public?

During last six months prior to separation
Since you emotionally separated

How Often did they put you down, call you names, swear at you, insult you in public?

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Showed excessive jealousy by constantly questioning, accusing, or threatening you? *

When did they show excessive jealousy by constantly questioning, accusing, or threatening you?

During last six months prior to separation
Since you emotionally separated

How Often did they show excessive jealousy by constantly questioning, accusing, or threatening you?

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Pressured you to have sex? *

When did they pressure you to have sex?

During last six months prior to separation
Since you emotionally separated

How Often did they pressure you to have sex?

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Slapped, kicked or pulled your hair, smothered you, twisted your arm, pinned you down, used force to put you out of the house? *

When did they Slap, kick or pull your hair, smother you, twist your arm, pin you down, use force to put you out of the house?

During last six months prior to separation
Since you emotionally separated

How Often did they Slap, kick or pull your hair, smother you, twist your arm, pin you down, use force to put you out of the house?

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Choked or strangled you, punched you with a fist, kicked you, hit you with something? *

When did they choke or strangle you, punch you with a fist, kick you, hit you with something?

During last six months prior to separation
Since you emotionally separated

How Often did they choke or strangle you, punch you with a fist, kick you, hit you with something?

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Threatened you with a knife, gun or other weapon? *

When did they threaten you with a knife, gun or other weapon?

During last six months prior to separation
Since you emotionally separated

How Often did they threaten you with a knife, gun or other weapon?

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Stabbed or shot you or used some other weapon to injure you physically? *

When did they Stab or shoot you or use some other weapon to injure you physically?

During last six months prior to separation
Since you emotionally separated

How Often did they stab or shoot you or use some other weapon to injure you physically?

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Threatened to hurt you or your children in any way? *

When did they threaten to hurt you or your children in any way?

During last six months prior to separation
Since you emotionally separated

How Often did they threaten to hurt you or your children in any way?

RELATIONSHIP CHARACTERISTICS

When you and your former partner were living together and when you became involved in disagreements or conflicts, how well did you stand up for yourself and state your position, compared to your former partner? *

Better
Equally Well
Less Well

At the present time, if you and your former partner became involved in a disagreement or conflicts, how well can you stand up for yourself and state your position, compared to your former partner? *

Better
Equally Well
Less Well

Since you separated, has your former partner stalked or harassed you making you feel unsafe? *

Since you separated, has your former partner called or messaged you at all hours of the day and night? *

Since you separated, has your former partner said hurtful things about you to your children? *

In the last six months of your relationship, did your former partner make you ask for money and/or account for all money you spent? *

Have you sought help for yourself as a result of abuse by your former partner? *

Is there anything else you would like us to know? *

If it is unsafe for us to contact you via telephone, please state the best time and way to contact you: *

Please read and acknowledge your acceptance of the following confidential information which you will be confirmed by submitting the document at the end of this form:

The Intake Coordinator, the Mediator and the Parties shall keep confidential all written and verbal information prepared, provided, disclosed, or exchanged during or for the purpose of the mediation.
Notwithstanding the aforementioned, the Mediator may, at their sole discretion, disclose information about the mediation:
- a) To communicate with the Parties, their lawyers or other legal representatives, and third parties retained by a Party, their lawyer, or other legal representative;
- b) Where ordered to do so by law;
- c) Where required to do so by law, including but not limited to obligations to report a child in need of protection; or
- d) Where the information indicates an actual or potential threat to human life or safety.

I give permission for Mediation Centre Ontario to contact the other party stated in this form to inquire about their interest in participating in Mediation. ** *

I agree to the disclosure and consent. *

Signature *

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