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:*

Street Address City State / Province / Region Postal / Zip Code

Work telephone:

Work Area Code

Work Prefix

Work suffix

Is it okay to leave a message at your work number?

Yes

Mobile telephone:

Mobile Area Code

Mobile Prefix

Mobile suffix

Is it okay to leave a message at your mobile number?*

Yes

Email address where you wish to receive private correspondence concerning your mediation:*

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:*

Yes

If yes or unsure, please explain what you signed.

Have you hired an attorney for this divorce? *

I have not spoken to an attorney.

I spoke to one, but have not retained one. (Consultation)

I have retained an attorney.

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?

City State

In which country were you married? (USA, Virgin Islands, etc)*

In which COUNTY (in the USA) were you married?

What are your living arrangements?

We are living in the same residence.

We are living in separate residences.

We are in the same residence, but consider ourselves to be separated.

I will explain in the comments section below.

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 separation/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:

Name of person referring you to Carolina Divorce Mediators (if applicable)

Do either you or your spouse have a Defined Benefit Pension Plan (DB)? A DB plan is a retirement plan that pays a certain MONTHLY dollar amount upon retirement. This is typical for military personnel, teachers, and other government employees. (NOTE: A DB Plan is NOT a 401k, IRA, or other similar account that is contributed to regularly where you receive a monthly or quarterly statement showing how much has been saved.)

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?

WHY US?

WE CARE

Divorce is a very stressful and emotional experience. Know that we care about you, your children, and your financial success. We’re going to see you through this.

EXPERIENCE

We are seasoned, full-time mediators. Not part-timers with day jobs trying to break into the business. It is through this expertise that fair and equitable agreements are reached.

IT’S ALL WE DO

Some mediators are the “Jack of all trades”. Not us. We are the Masters of one. Divorce. We do nothing else.

YOUR CHILDREN’S SECURITY

We are your starting point to insure that your children get what they need. We help them by helping you. It’s our prime directive.

COSTS ARE LOWER

Not only lower, but inexpensive compared to attorney led negotiations. No reason to spend your kid’s college savings on your divorce.

FINANCIAL SECURITY

Money is necessary. It is needed to provide for ourselves and our children. But sometimes financial issues can be quite challenging. We’ll step you through it.