Mediation Client Intake Form

Gather each party's personal, family, employment and financial background before the first session. Built for family and divorce mediators who want a clear picture of the case and the likely points of disagreement from day one.

Use this template

In the Claude connectors directory

Full name

First Name

Last Name

Home address

Street Address

City

State / Province

ZIP / Postal Code

Mobile phone number

Home phone number

Work phone number

May we call you at work?

Yes No Not sure

May we contact you by email?

Yes No Not sure

May we share this email address with the other party?

Yes No Not sure

Date of birth

Place of birth

Education level

If you hold a graduate degree, what type?

Date of marriage

Where were you married?

Religious or civil ceremony?

Additional children of this marriage living in the household

Do any of the children have special educational or medical needs?

Yes No Not sure

If yes, please specify

What best describes your children's awareness of the marital situation?

Do you expect a dispute over custody of the children?

Yes No Not sure

Who first raised the idea of separating or divorcing?

Me My spouse Mutual decision

How did the other person react?

Do you currently live with your spouse?

Yes No Same home but separated

If not, when did you separate?

If you live apart, who initiated it?

Me My spouse Mutual decision

Whose idea was it to begin mediation?

Mine My spouse's Both of us A third party

How did you hear about our services?

What best describes your current situation?

Tell us one positive thing about the other party

Is there any legal reason you cannot communicate directly or indirectly (e.g., a protection order)?

Professionals consulted previously

1) Marriage counselor or therapist you both saw

1a) Approximate date of last contact

2) Individual therapist you see or have seen

2a) Approximate date of last contact

3) Attorney consulted about separation or divorce

3a) Approximate date of last contact

Employment and income

Occupation

Job title

Employer name

Work address

Street Address

City

State / Province

ZIP / Postal Code

Time at current job

Gross salary

Do you have any other regular income?

Yes No Not sure

If yes, enter the amount

If yes, enter the source

Which benefits does your employer provide?

Health insurance Dental coverage Life insurance Retirement plan Stock or stock options Company car Other

If "Other", please specify

If you selected "Business", please describe it

If you selected "Cars", please describe them

Do you hold any of the following financial assets?

Checking account Savings account Investment account Retirement account Cryptocurrency None

Account ownership

In my name In my spouse's name Joint

Retirement plans

Employer plan Individual retirement account Pension None

Do you have any major debts?

Yes No Not sure

If yes, please describe them

Household finances have been handled by

Me My spouse Both of us

Health plan name

Your member ID

Coverage is provided by

My employer My spouse's employer Private plan Public program

Does the insurance cover your children?

Yes No Not applicable

List any previous marriages, any children with their ages and who they live with, and any financial arrangements with your former spouse

Briefly describe the history of your current marriage or relationship

Do you have concerns about being in the same room as your former partner?

What do you see as the biggest obstacle to reaching an agreement?

Main reasons for the separation

If other, please describe

Is there any police record on file?

Yes No Not sure

Is there any child protective services case on file?

Yes No Not sure

Do you have any disabilities we should know about?

Are there any other facts or circumstances relevant to seeking mediation now?

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