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The Center for Families, LLC Helen Elliott Wheeler, M.Ed. LPC 27 Gamecock Ave. #202 Charleston, SC 29407

FAMILY MEDIATION INTAKE FORM

Date: ______

Names/Contact Info for All Parties Involved:

Name: ______

Address: ______

Home Telephone No.: ______cellphone: ______

Work Telephone No.: ______Employer: ______

Date of Birth: ______Occupation: ______

Work Hours: ______e-mail______

Name/Contact Info. of Attorney: ______

______

Name: ______

Address: ______

HomeTelephone No.: ______Cellphone:______

Work Telephone No.: ______Employer: ______

Date of Birth: ______Occupation: ______

Work Hours: ______e-mail______

Name/Contact Info. of Attorney: ______

______Marital status of parties: ______

If married, list date/place of marriage: ______

______

Any Court Orders issued (including Orders of Protection)?

______

Children (names, birthdates & current living arrangements):

______

______

______

Voluntary or Court-ordered Mediation? ______

Initial issues parties want to mediate:

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