Working Past Conflict Application » Mediation & Facilitation Resources

In the interest of saving you time and money, I am asking that you complete this form and bring it with you to our first meeting. You will have the opportunity throughout our work to further explain any items.

If you would prefer to print out the form and submit it by mail or in person, you may download a print-friendly version [pdf]

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Name

Date of application

Mailing address

Email address

Telephone

Name of the other parent of your children

Contact information for them including phone, email, address

Names and ages of children:

Referred to this class by (check all that apply):

Judge/Magistrate
Attorney
Guardian ad Litem
Other

Referring judge:

Town of court:

Referring attorney:

Other referral details:

Brief history:

Year of marriage

Year of divorce

OR divorce pending

Is there now or was there a Guardian ad Litem?

If yes, please name Guardian ad Litem

Are there active Protection from Abuse orders?

If yes, are you allowed to be in one another's presence for parenting discussions?

Describe briefly the issues presented to the court.