Divorce Mediation Intake Form

MEDIATION INTAKE FORM

First, please review the Consent to Joint Orientation and the Rules below.

Rules for Mediation Orientation

1. Mediation is a voluntary process. No one can be “forced” into mediation. Both parties must
agree, and be present, to use mediation.
2. Although Kelly Chang Rickert is an attorney, you have chosen to hire her in a capacity of a
mediator. Thus, she is not acting as either of your attorneys in any capacity, and there shall be no attorney-client privilege, as detailed in the Disclosure form attached. Kelly Chang Rickert cannot give you legal advice in her capacity as a mediator
3. Neutrality is central to mediation. Thus, Kelly will not communicate with either of you without
the other party’s knowledge, or consent. Kelly will not return any phone calls or emails in between sessions unless both of you are on the phone and on the email chain. This helps preserve the neutrality of the mediator, which is essential to the success of mediation.
4. Though we strongly believe mediation is the BEST way to resolve disputes, it may not be
appropriate in the following scenarios:
a. When one party refuses to mediate;
b. If there is domestic violence in your matter;
c. When one or both parties is hiding assets;
d. When one or both parties refuse to negotiate fairly.

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Mediation is a voluntary process. No one can be “forced” into mediation. Both parties must agree, and be present, to use mediation.
Party 1: I have reviewed and understand the Disclosure and Waiver of Privilege, as well as the Disclosure and Waiver of Conflict of Interest, and I consent to the Joint Orientation.
The Joint Mediation Orientation shall not proceed until both parties have read the Disclosure and Waiver of Privilege, as well as the Disclosure and Waiver of Conflict of Interest.
Mediation is a voluntary process. No one can be “forced” into mediation. Both parties must agree, and be present, to use mediation.
Party 2: I have reviewed and understand the Disclosure and Waiver of Privilege, as well as the Disclosure and Waiver of Conflict of Interest, and I consent to the Joint Orientation.
The Joint Mediation Orientation shall not proceed until both parties have read the Disclosure and Waiver of Privilege, as well as the Disclosure and Waiver of Conflict of Interest.
If yes, please provide case number.
Please indicate if this is disputed.
If yes, please provide names and DOB for all children.
If this is disputed, please indicate what each party desires.
If yes, please specify.
If employed, please provide name of employer, position, salary/earnings, employment benefits, retirement benefits.
If employed, please provide name of employer, position, salary/earnings, employment benefits, retirement benefits.
Please indicate Description, Date of Acquisition, Present Location, Source and Nature of Consideration, Purchase Price, Current Fair Market Value and Encumbrances
Please indicate Description, Date of Acquisition, Present Location, Source and Nature of Consideration, Purchase Price, Current Fair Market Value and Encumbrances
Please indicate Description, Date of Acquisition, Present Location, Source and Nature of Consideration, Purchase Price, Current Fair Market Value and Encumbrances
Amicable/contentious?
Please note that if there is a history of violence, mediation is probably not appropriate.
Please specify