Family Mediation Intake Form
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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: