MEDIATION

Each party must complete and submit the information below.

Opposing Party

For divorce/separation matters, this would be your spouse. For custody, access and child support matters, this would be the other parent.
Full Legal Name *

First Name Middle Name Last Name
Preferred Name (if different than above)

First Name Last Name
Surname at birth and/or any other name(s) used
Date of Birth *

- Month - Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone (Home)

- Area Code Phone Number
Phone (Work)

- Area Code Phone Number
Phone (Cell)

- Area Code Phone Number
E-mail

Will and Power of Attorney
You should modify your Will and Power of Attorney (POA) after separation as these documents may not reflect your current wishes. If you do not have a Will and POA, your spouse, even while separated, could be entitled to your estate.
Would you like us to provide you with information relating to Wills and Powers of Attorney? *

Yes, please contact me. No, I am not interested.

Legal Proceedings
Have you consulted a lawyer?

Yes No
Has the opposing party already commenced legal proceedings?

Yes No
Did you sign a Cohabitation agreement or Marriage Contract prior to your relationship/marriage?

Yes No
We will require a copy of the agreement.

Relationship Information
Date you started living together

- Month - Day Year
Date of marriage

- Month - Day Year
Date of separation

- Month - Day Year
Date of divorce (if applicable)

- Month - Day Year
Are you currently in a new relationship?

Yes No
Please provide us with your current partner's full name
Is the Opposing Party currently in a new relationship?

Yes No Unsure
Please provide us with the Opposing Party's current partner's full name

Employment
A. You
Employer
Position/Title
Years with current employer
Annual Salary
B. Opposing Party
Employer
Position/Title
Years with current employer
Annual Salary