PERSONAL DATA AND INFORMATION

1. Name
Home Address
Street
City

state
Zip

Work Phone
Home Phone

Best way to contact you:
E-mail

2. Age

3.Date of Marriage
Date of Separation

 Full Name Date of BirthResiding With
child 1
child 2
child 3

Are you currently paying support for these children? Yes No

 Full Name Date of BirthResiding With
child 1
child 2
child 3

Are you currently paying support for these children?  Yes No

6.Other than your children and/or your spouse, are there any people living with you now?  Yes No

If yes, list their names and their relationship to you

7.Are you employed?  Yes No

If yes, give name of employer:

Address of employer

8. Highest level of education attained

Field(s) of study

9.Do you have an interest in reconciliation?  Yes No

As far as you know, does your spouse? Yes No

10.Are you presently seeing a counselor or therapist?  Yes No

If yes,  Individual Joint Family

Please list name of counselor or therapist

11. Have you previously seen a counselor or therapist? Yes No

If yes,  Individual Joint Family

12.Do you anticipate a dispute about custody of the children? Yes No

13. Do you presently have an attorney? Yes No

If yes,

Name

Address

Phone

14. Are there joint bank accounts to which your spouse has access?  Yes No

15. Does your spouse have credit cards you are responsible for?  Yes No

16. Do you have a will? Yes No

17.How did you learn about Diana Mercer and Peace Talks Mediation Services?

(Give name and relationship, where applicable)

18.Security Code