Mediation Intake Form - Joseph Law Group, P.C.

Information regarding yourself:

Name:

Maiden name:

Address:

City:

State:

ZIP:

E-mail:

Referred by:

Telephone:

Home:

Work:

Cell:

Preference/Restrictions:

Date of birth:

Place of birth:

Employer:

Date hired:

Employer's address:

Job title/position:

Annual income:

Attorney, if any:

Address:

Telephone No.:

Education:

Highest grade completed:

Degrees &/or licenses:

Number of prior marriages:

How ended:

General Information:

Date of marriage:

Religious or Civil:

Town or City & State of marriage:

Approximate dates when:

Met spouse:

Began dating:

Engaged:

Separated:

Do you have a:

Prenuptial agreement?

YesNo

Postnuptial agreement?

YesNo

Do either both of you have a:

Will?

HusbandWifeNeither

Health care proxy?

HusbandWifeNeither

Information regarding your child(ren):

Has either of you ever sought and Order of Protection, or had one filed against you?

YesNo

Do either of you have any pending legal matters? If so, please describe:

Information regarding yourself:

General Information:

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