Mediation Information Form

Please take a few moments to complete this private and confidential information form. It is the first step of the confidential mediation process. The process can only begin when we have received both parties’ information forms. Meditation services are available in-person and remote via technology for all locations.

Once we have received both parties’ information forms, the mediator who is assigned to your case will contact you individually to set up your confidential intake meetings. These meetings are free of charge. During the intake meetings, the mediator will assess if your case is suitable for mediation. Some cases may not be appropriate for mediation.

If you currently have a court date and/or have a court file number, On-Site mediation will be provided to you free of charge for matters that can be addressed in two hours or less. If you do not have a court date and/or have a court file number, The Ministry of Attorney General subsidizes family mediation fees for off-site mediation. These fees are charged based on each person’s income. Click here for the fees schedule.

We encourage all clients to obtain legal advice before, during and after all mediations.

- Step 1 of 10

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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?

Please state the level of education you have received:

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:

Apt/ Unit:

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Other Party's City:

Other Party's Province

Postal Code:

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Other Party Phone (Primary) *

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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Lawyer's Name:

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?

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Child Name:

Age:

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Child Name:

Age:

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Child Name:

Age:

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Child Name:

Age:

Add if required:

Are you in a new relationship?

Do you have children from another relationship?

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Child Name:

Age:

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Child Name:

Age:

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Child Name:

Age:

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Child Name:

Age:

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?

During last six months prior to separation
Since you emotionally separated

How Often?

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Threatened to hurt or kill you? *

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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Pressured you to have sex?

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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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?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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Threatened you with a knife, gun or other weapon?

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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

When?

During last six months prior to separation
Since you emotionally separated

How Often?

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:

I agree to the disclosure and consent. *

Signature *

Clear Signature

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