<p> The Center for Families, LLC Helen Elliott Wheeler, M.Ed. LPC 27 Gamecock Ave. #202 Charleston, SC 29407</p><p>FAMILY MEDIATION INTAKE FORM</p><p>Date: ______</p><p>Names/Contact Info for All Parties Involved:</p><p>Name: ______</p><p>Address: ______</p><p>Home Telephone No.: ______cellphone: ______</p><p>Work Telephone No.: ______Employer: ______</p><p>Date of Birth: ______Occupation: ______</p><p>Work Hours: ______e-mail______</p><p>Name/Contact Info. of Attorney: ______</p><p>______</p><p>Name: ______</p><p>Address: ______</p><p>HomeTelephone No.: ______Cellphone:______</p><p>Work Telephone No.: ______Employer: ______</p><p>Date of Birth: ______Occupation: ______</p><p>Work Hours: ______e-mail______</p><p>Name/Contact Info. of Attorney: ______</p><p>______Marital status of parties: ______</p><p>If married, list date/place of marriage: ______</p><p>______</p><p>Any Court Orders issued (including Orders of Protection)?</p><p>______</p><p>Children (names, birthdates & current living arrangements): </p><p>______</p><p>______</p><p>______</p><p>Voluntary or Court-ordered Mediation? ______</p><p>Initial issues parties want to mediate: </p>