Name * First Name Last Name Email * Name of other party * What brings you to mediation? * Check all that apply Divorce Custody Estate Elder Care Personal Injury Something else Please provide a general list of what you would like to resolve during mediation. * Do you currently have a pending court date? * Yes No If so, when and with what judge? Have you secured the services of an attorney? * Yes No No, but I am actively looking If you have secured the services of an attorney, what is their name and at what firm do they practice? Have there been any instances of domestic violence in your relationship? * Yes No If yes, please describe Have law enforcement or DCFS conducted investigations related to your family? * Yes No If yes, please describe Do you have access to a high-quality internet connection? * Yes No Do you feel confident that you can honestly speak during mediation without being threatened or intimidated by the other party or by outside parties? * Yes No If no, please explain Is/are there any relevant circumstance(s) your mediator should know about prior to mediation? * Do you agree to mediate in good faith and to actively participate in reaching a satisfactory resolution to the best of your ability? * Yes No Thank you!
