This form is to be used to request the mediation of a divorce.  This form is meant to gather basic information.  Additional information may be requested prior to the start of the mediation.  An intake specialist or your mediator will contact you with more details or to request additional information once the mediation has been scheduled.

AMS understands that the information you are providing is of a sensitive and personal nature.  Please be assured that all the information on this form will be kept in the strictest confidence.  No information will be released to any other individual without your express written consent.

Divorce Mediation Intake Form

 

Preferred Mediation Date:

 

1st Optional Date:

 

2nd Optional Date:

 

Preferred Mediation Session: - Selection Required - Half-Day Mediation Full-Day Mediation Not Sure

Preferred Mediation Session: :: Many cases only required a half-day or 4 hour mediation. However, some divorce mediations involving complex assets or child custody issues may take longer. If you wish to schedule for a Half-Day Mediation initially, AMS will schedule additional time with you as necessary should you be unable to find resolution within the timeframe allotted.

 

Mediation Start Time: - Optional Field - 9:00 AM - Morning Mediation 1:30 PM - Afternoon Mediation

Mediation Start Time: :: All Full-Day Mediations begin at 9:00 AM and are scheduled through 4:30 PM with a lunch break.

 

Has the date and time of the mediation been agreed to by your spouse? - Selection Required - Yes No Not Sure

Has the date and time of the mediation been agreed to by your spouse? :: If you have been unable to confirm the time with your spouse, then AMS will attempt to confirm it for you.

 

Relationship History

 

How long have you and your spouse been married?

How long have you and your spouse been married? :: Please enter time in year and month format. Example: 10 years 3 months

 

Has there ever been any physical or emotional violence in the relationship? - Selection Required - Yes No

Has there ever been any physical or emotional violence in the relationship? :: Please included any instances, even if they were not reported to the police.

 

If violence has been present in the relationship, please provide an explanation here:

If violence has been present in the relationship, please provide an explanation here: :: Please list instances and time/dates that they occurred to the best of your recollection.

 

Are there now or have there ever been any restraining/protective orders? If so, please complete the following:

 

Reason for the order:

 

Effective Date of the Order:

 

Current status of the order:

Current status of the order: :: Please tell us whether the order is still in effect, has expired, has been lifted, etc.

 

Do you have any apprehension regarding emotional and/or physical intimidation from your spouse or anyone that might accompany him/her?

 

Do you feel comfortable being in the same room with your spouse? - Selection Required - Yes No Not Sure

Do you feel comfortable being in the same room with your spouse? :: If you are not sure, you can discuss this matter further with your mediator to help better understand the process and how you are protected during the process.

 

Have you or your spouse filed with the courts a petition for divorce? If so, please complete the Court Information section. If not, please skip to Your Personal Information.

 

Court Information

 

Case Name or Style No.:

 

Cause No.:

 

In which court was the petition for divorce filed?

In which court was the petition for divorce filed? :: Please be more specific than "Dallas". Example would be "Dallas County - 303rd Family Court", etc.

 

Is this a court-ordered mediation? - Selection Required - Yes No

 

Status Report Date:

Status Report Date: :: This is the date that you must report back to the court about the outcome of the mediation.

 

Hearing Date:

Hearing Date: :: When is the next hearing date scheduled for your divorce?

 

Your Personal Information

 

Contact Info

 

Sex

Male
Female

 

First Name:

 

Last Name:

 

Mailing Address:

Mailing Address: :: Please provide the address where you will be able to receive correspondence regarding your case.

 

Primary Telephone #:

Primary Telephone #: :: Please provide the primary contact number where you wish to be reached regarding your case.

 

Secondary Telephone #:

Secondary Telephone #: :: Please provide a secondary contact number, should we be unable to reach you at your primary number.

 

Home Email Address:

Home Email Address: :: Please provide your home email address for communication purposes.

 

Education/Employment Info

 

What is the highest level of education that you have completed? - Selection Required - Some High School GED High School Graduate Some College Some Trade/Technical School Associates Degree Trade/Technical School Degree College Coursework Certificate (such as LVN, Paralegal, HVAC Tech, etc.) Bachelors Degree Masters Degree Doctorate JD MD

What is the highest level of education that you have completed? :: Please select the highest level of education that you've attained.

 

Are you currently employed? If so, please complete the following questions about your employer. If not, please skip to the Attorney Information section.

 

Employer's Name:

Employer's Name: :: If self-employed, please type 'self' in this field.

 

Employer's Address:

 

Employer's Telephone #:

Employer's Telephone #: :: Please enter your contact number at work or the main number for your employer.

 

Your Position:

Your Position: :: Please enter your position with your employer (ie. - manager, shift supervisor, maintenance, call center rep, etc.)

 

Your Work Email Address:

 

Attorney Information

 

If you have retained an attorney for your divorce, please complete the following fields. If not, please skip to the About Your Spouse section.

 

Attorney's Name:

 

Attorney's Firm Name:

 

Attorney's/Firm's Address:

 

Attorney's Telephone #:

 

Attorney's Fax #:

 

Attorney's Email Address:

 

About Your Spouse

 

Your Spouse's Full Legal Name:

Your Spouse's Full Legal Name: :: Please enter your spouses full legal name as she is known by others.

 

Spouse's Address:

Spouse's Address: :: If you and your spouse are no longer residing together, please enter his/her address here. Otherwise, type "N/A". If you don't know your spouse's address, type "Don't Know".

 

Spouse's Telephone #:

Spouse's Telephone #: :: If you do not currently have a contact number for your spouse, please type "don't know" here.

 

Spouse's Email Address:

 

Has your spouse retained an attorney? - Selection Required - Yes No Don't Know

 

About Your Children

 

Please complete all applicable information. If there are no minor children involved in this divorce, please select the radio button below and proceed to the About Your Assets section.

 

Children Involved?

There are no minor children involved in this divorce.

 

How many children are a product of this marriage?

How many children are a product of this marriage? :: Enter only the number of children that will need custoday arrangements made for them.

 

Please provide details about each child. Please place your mouse over the blue information button to see details on how to complete this field.

Please provide details about each child. Please place your mouse over the blue information button to see details on how to complete this field. :: Please list each child's First Name, Age, Gender, and with whom they are currently residing. For example: "Jenny, 9, Female, Mom". Please start each child's information on a new line.

 

About Your Assets

 

Please provide the following general information regarding your assets to the best of your ability. A detailed assets worksheet will be included in the mediation packet that you will receive in the mail once your mediation has been scheduled.

 

Total Value of Joint Assets:

Total Value of Joint Assets: :: Please enter the dollar amount, in 0.00 format, that most closely represents the value of the assets that you and your spouse hold jointly.

 

Total Value of Your Separate Assets:

Total Value of Your Separate Assets: :: Please enter the dollar amount, in 0.00 format, that most closely represents the value of the assets that you hold separately and apart from your spouse.

 

Total Value of Your Spouse's Separate Assets:

Total Value of Your Spouse's Separate Assets: :: Please enter the dollar amount, in 0.00 format, that most closely represents the value of the assets that your spouse holds separately and apart from you.

 

Image Verification