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Family Court and Child Custody Mediation Intake Form

1.Please enter your personal information(Required.)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone Number

2.Please list other names you may have used in the past (first and last):(Required.)

3.Please provide your birthday (mm/dd/yyy):(Required.)

4.Please provide your court case number:(Required.)

5.Full name of other parent (or other person in this court action):(Required.)

6.Please list children involved in this court action:(Required.)

Name:

Birthday (mm-dd-yyyy):

School Name and City:

Name:

Birthday (mm-dd-yyyy):

School Name and City:

Name:

Birthday (mm-dd-yyy):

School Name and City:

Name:

Birthday (mm-dd-yyyy):

School Name and City:

7.Please list the name and ages of other parties living in your household (NOT parties to this case)(Required.)

8.Do you have an attorney?(Required.)

Yes

No

9.If yes, please provide attorney's name (first and last)

10.Have you been in mediation at Butte or any other county before?(Required.)

Yes

No