Client Information Data Entry

Each spouse should enter their respective information into this page.  YOUR RESPONSES ARE CONFIDENTIAL AND WILL NOT BE SHARED WITH YOUR SPOUSE.  Upon completion, it will automatically be sent to our office and used to prepare your file. Please complete this form in its entirety. Please note that almost all of the responses are REQUIRED.   

First name:
Middle name:
Last name:
Suffix
Name by which you wish to be addressed:*
Your age:*
YOUR date of birth:
Month: (You)*
Day (You)*
Year (You)*
Your spouse age:*
Your SPOUSE date of birth:
Month: (Spouse)*
Day (Spouse)*
Year (Spouse)*
Address:*
Work telephone:
Work Area Code
Work Prefix
Work suffix
Is it okay to leave a message at your work number?
Mobile telephone:
Mobile Area Code
Mobile Prefix
Mobile suffix
Is it okay to leave a message at your mobile number?*
Email address where you wish to receive private correspondence concerning your mediation:*
Highest Level of Education you attained:
Current Occupation:
Current Employer:
What is your annual income? $*
What do you believe is your spouse's income? $
Have you and your spouse signed ANY TYPE of agreement or do you have any court orders currently in effect? If unsure, please explain:*
If yes or unsure, please explain what you signed.
Have you hired an attorney for this divorce? *
If yes, what is the attorney's name?
On what date did you and your spouse get married?
Marriage Month *
Marriage Day*
Marriage Year*
Where were you married?
In which country were you married? (USA, Virgin Islands, etc)*
In which COUNTY (in the USA) were you married?
What are your living arrangements?
On what date did you begin living in separate residences?
Separation month
Separation day
Separation year
Please list all children of THIS marriage regardless of age (please provide FULL legal names).
First name: (Child 1)
Middle name: (Child 1)
Last name :(Child 1)
Child #1 gender:
Birth Month: (Child 1)
Birth Day: (Child 1)
Birth Year: (Child 1)
We call this child (#1) by the name of:
First name: (Child 2)
Middle name: (Child 2)
Last name :(Child 2)
Child #2 gender:
Birth Month: (Child 2)
Birth Day: (Child 2)
Birth Year: (Child 2)
We call this child (#2) by the name of:
First name: (Child 3)
Middle name: (Child 3)
Last name: (Child 3)
Child #3 gender:
Birth Month: (Child 3)
Birth Day: (Child 3)
Birth Year: (Child 3)
We call this child (#3) by the name of:
First name :(Child 4)
Middle name: (Child 4)
Last name: (Child 4)
Child #4 gender:
Birth Month: (Child 4)
Birth Day: (Child 4)
Birth Year: (Child 4)
We call this child (#4) by the name of:
First name :(Child 5)
Middle name: (Child 5)
Last name: (Child 5)
Child #5 gender:
Birth Month: (Child 5)
Birth Day: (Child 5)
Birth Year: (Child 5)
We call this child (#5) by the name of:
The initial decision to separate/divorce was *
I have no desire to reconcile:*
I don't blame my spouse for our separtion/divorce:*
I want to punish my spouse:*
I wish to stay on good terms with my spouse.*
I wish to remain an active parent for my children (if applicable).
I wish that my spouse remains an active parent (if applicable).
My spouse is a good parent (if applicable).
I am a good parent (if applicable).
I understand my/our financial situation.*
I believe I should get more of our assets (home, retirement, bank accounts) than my spouse:*
Alcohol or drug abuse is not an issue in our relationship.*
Violence is not an issue in our relationship*
Infidelity is not an issue in our relationship.*
I believe that we will reach a fair agreement in mediation.*
What are your priorities when you mediate? In other words, how do you want to share the kids? Do you wish to sell/keep/stay in the marital home? What do you want out of the settlement? What about retirement funds? Debt? Alimony?
Priority 1:
Priority 2:
Priority 3:
Priority 4:
Priority 5:
Where did you hear about Carolina Divorce Mediators? *
Name of person referring you to Carolina Divorce Mediators (if applicable)
When people decide to mediate, they usually do so to save money, time, and avoid going to court. Other than these reasons, why do you wish to mediate?
Additional Information - Use this area to tell us about any other information that is meaningful to you. Examples might be explanations to questions above, roadblocks to your discussions, high conflict subject areas, or anything else that you believe is important. Please be as complete as possible.
Above you indicated that there were issues with alcohol or drugs. Would you please share a little bit about that?
Above you stated that violence could have been an issue in the past. Would you share a little more about that?
Above you stated you felt infidelity was an issue in your marriage. Please elaborate.
You mentioned above you were not optimistic about reaching an agreement in mediation. Why do you feel this way?