CLIENT INTAKE FORM 

YOUR CONTACT INFORMATION 

FULL NAME:

BIRTHDATE: 

ADDRESS: 

E-MAIL ADDRESS: 

PHONE NUMBER: 

BEST WAY TO REACH YOU: 

CHILDREN 

FULL NAME: 

BIRTHDATE: 

FULL NAME:

BIRTHDATE: 

FULL NAME: 

BIRTHDATE: 

MARRIAGE HISTORY 

DATE YOU STARTED LIVING TOGETHER: 

DATE OF MARRIAGE: 

DATE OF SEPARATION: 

WORK INFORMATION 

If employed:

WHERE DO YOU WORK: 

JOB TITLE:

ADDRESS: 

WHAT IS YOUR GROSS ANNUAL PAY *:

If self employed: 

NAME OF BUSINESS: 

NATURE OF BUSINESS: 

NUMBER OF EMPLOYEES: 

GROSS ANNUAL INCOME FOR THE BUSINESS *: 

VALUE OF THE BUSINESS *: 

• Do your best for now to answer the financial questions. Amounts will need to be verified later.

MEDIATION GOALS 

WHAT ISSUES WOULD YOU LIKE TO ADDRESS IN MEDIATION?: 

IS THERE ANYTHING ELSE YOU’D LIKE TO MENTION?:

Thank you for taking the time to complete this form.  

Please save as a PDF and email it to me as as an attachment to dodie.sobretodo@mac.com.