WPC z3U]X'Xp>;m% Ni?]j7K Ш!%XWAM\c~ea,1b3Q9*}tFXĸHGje5 5"B#   .,?   .,@   .,A  .,B  #}XX=K#X=X}  XS XXX=# XXS!#uFamilyMediationCentre#u"##}!#  ̀ Off-Site Intake/ScreeningFormX=X}Ԁ#}XX="#X=X} \ #}XX=%##X=X} @ 3.Whenreflectingonyourmarriage/relationship,whathasbeenthemost "` Ѐpositiveaspects#}XX=|##X=X}Ԁandwhathasbeenthemostnegative#}XX=H$#X=X}Ԁ?  L Ѐ  8 Positiveaspects#}XX=$#X=X}_________________________________________________________________  $  ______________________________________________________________________________   ______________________________________________________________________________   ______________________________________________________________________________ n Negativeaspects_#}XX=5%#X=X}_______________________________________________________________ F _____________________________________________________________________________ \ ______________________________________________________________________________ 4 ______________________________________________________________________________   ̀#}XX= '#X=X}  Ѐ4.Areyoucurrentlyinanewmarriage/common-lawrelationship?  ЀYES()NO() ~ Ѐ j  @ Ifso,sincewhen?_____________Nameofcurrentpartner:_______________________ V Ѐ B  @ Doyouhaveotherchildrennotmentionedabove?YES()NO() .l Ѐ  X  ЀChildrenfromthisnewrelationship. !D! Ѐ !0 " Ѐ "!# * .W*d d ddm dd m dd dd Xdd X dd .Ws#s#, dd ,Xdd ,dd ,dd ,N dd +  $#"$#" $ChildsName '.$l"%" 'M/F '.$l"&" 'DateofBirth '.$l"'" 'Age '.$l"(" 'ChildnowLivingwith#}XX=(#X=X}Ԁ .$l")"   %#*   %#+   %#,   %#-   %#.   .'l%/   .'l%0   .'l%1   .'l%2   .'l%3   (&4   (&5   (&6   (&7   (&8   .*l(9   .*l(:   .*l(;   .*l(<  .*l(=  ̀ 6,t*> ̀ .L,@  .8-A Ї̀XS XXX=# XXS-#uFamilyMediationCentre#ul0##}*0#  ̀ Off-Site Intake/ScreeningFormX=X}Ԁ#}XX=*1#X=X} 2p  @ 5.Pleaseprovide(withasimpleexplanation) whatyouperceive astheissuesforMediation.. "`     Issues0 ` 0 ` s#` s#0 s# s#0hs#s#0hs#hs#WhyisthisaConcern?  8s#s#   a__________________0 h 0hs#hs#__________________________________________    __________________________________________   __________________________________________ s#s#     b__________________0 h 0hs#hs#__________________________________________   __________________________________________ n __________________________________________Zs#s#   c__________________0 h 0hs#hs#__________________________________________ 2p __________________________________________ \ __________________________________________ Hs#s#     d__________________0 h 0hs#hs#__________________________________________   __________________________________________   __________________________________________s#s# #}XX=u1#X=X}̀6.a)Haveanylegalproceedingscommencedincourt?YES()NO() ~ Ѐ j   Ifyes,pleaseprovidethefollowing: V Ѐ B   a.courtfile#________________ .l Ѐ  X  Ѐb.nextcourtdate_____________ !D! ̀c.orderoragreementcurrentlyinforce__________ "!# e  b)HaveyouhavesignedSeparationAgreementwithyourformerpartner?YES()NO() $"%  (#3p$""  >t:0  0` ##2#  i  .3  0 ` #` #  Whenwasitsigned____________________________t::݌&$' # # Ќ  ""  ;0  0` ##2#  ii  .3  0 ` #` #  Arethereissuesthatyouwouldliketorevieworchangeinthisagreement? f(&) Ѐ;;݌  # # Ќ    Pleasedescribe__________________________________________________________ >*|(+    ` ________________________________________________________________ ,T*-      `  .-0 Ї   `      ӀXS XXX=# XXSD7#uFamilyMediationCentre#u>##}G>#  ̀ Off-Site Intake/ScreeningForm 2p :>X=X}̀7.a.Areyouenteringintomediationvoluntarily?YES()NO() H Ѐ 4 r   IfNo,Pleaseexplain:________________________________________________  ^   __________________________________________________________________  6    __________________________________________________________________      b.WhyhaveyouchosenmediationtoresolveyourFamilyLawmatter?    Pleaseexplain:#}XX=m?#X=X}________________________________________________ l   __________________________________________________________________ D   __________________________________________________________________ Z  (#33  0   9.Arethereanyothersignificantadultsinvolvedinthecareofyourchildren?##    ` (ie.grandparents,otherfamilymembers,daycareproviders?)     __________________________________________________________________    __________________________________________________________________ |   __________________________________________________________________ T ̀9.Whatisthehighestlevelofeducationyouhavecompleted? (circlenumber)  "V " Ѐ #F!# Ѐ0  1.lessthanhighschool2.highschooldiploma#2"$## Ѐ $#%   3.somepost-secondaryschooling4.college/technicaldegree % $& Ѐ &$'   5.universitydegree,undergraduate6.other___________ '%( Ѐ (&) Ѐ |)'* Ѐ10.Inwhichofthefollowinggroupsdoesyouryearlygrossincomefall? #}XX=A# }(circlenumber)#} H# X=X} h*(+ Ѐ h+), Ѐ0  1.lessthan$15,0002.$15,000-$29,999T,*-## Ѐ @-~+.   3.$30,000-$59,9994.$60,000ormore#}XX= I# ,.j,/  /V-0 Ї  }uFamilyMediationCentre#uJ##}ӉJ#  ̀Off-SiteIntake/ScreeningForm F ̀ j   Ӏ0  X=X}11.Whatisyouryearlygrosshouseholdincome?(Incomefromallsourcesinyour | Ѐcurrenthome.Forexample,newpartners,workerscompensation-allincome  Ѐotherthanchildsupport.) (circlenumber) #}XX=K#X=X}z ## Ѐ j    0 ` 1.lessthan$15,0002.$15,000-$29,999V ` #` # ̀0 ` 3.$30,000-$59,9994.$60,000ormore. l ` #` # KӀ X    Ӏ D    12.Whichofthefollowinglanguagesdoyouunderstandandspeakthebest? 0 Ѐ  Ѐ0  0` ##1.English2.French3.other_____________` #` # Ѐ  Ѐ  Ѐ0  13.a)Whichofthefollowingbestdescribeswhereyouliveatthemoment?## ̀0 ` 1.housingownedwithamortgage2.housingownedwithoutamortgagef` #` # ̀0 ` 3.housingrentedprivately4.housingrentedfromOntario Housing>|` #` # ̀0 ` 5friend/relativesnorent6.friend/relativepayingrentX` #` # Ѐ D   0 ` 7.other____________________________________0` #` # Ѐ  Ѐb)Areyoucurrentlylivinginthematrimonialhome?  Ѐ  Ѐ0 ` 1.yes2.no` #` # ̀c)Atthetimeofyourfinalseparation,whomovedoutofthefamilyhome? z!! Ѐ f" "   1.me2.partner3.both4.neither R#!# Ѐ >$|"$ ̀14.Howoldwereyouwhenyouandyourpartnergotmarriedorbeganlivingtogether? &T$& ̀Me:__________yearsoldPartner:_________yearsold ',&( Ѐ    b.,/ ЀXS XXX=# XXSM#uFamilyMediationCentre#uU#XS X#X=X XXSU#   fU  Ӏ Off-Site Intake/ScreeningForm  ^ VӀ N Ѐ15.Whomadethedecisiontoseparate? : Ѐ &   1.me_______________2.partner____________3.both__________  Ѐ  Ѐ   Ѐ16.Coupleswhoseparate/divorcedosoforanumberofreasons.Pleaselistthe    Ѐ   Ѐ   ` 3whichbestsuityourreasonsforseparating: p    #1.Reason_____________________________________________________________ H  ______________________________________________________________________________  ^   #2.Reason______________________________________________________________ 6 ______________________________________________________________________________    #3.Reason______________________________________________________________  ______________________________________________________________________________  Ѐ l Ѐ17.a)Areyouandyourpartnerlivinginseparateresidencesatthistime? X Ѐ D   0 ` 1.no(seec)2.yes(seeb)0n` #` # ̀b)Ifyeswhatdatedidyoubeginlivingseparately? F ̀0 ` month__________year________.` #` # Ѐ    Ѐc)Ifnopleaseexplainthecurrentarrangements.  ! ______________________________________________________________________________ " # ______________________________________________________________________________ h$"% ______________________________________________________________________________ @&~$' ______________________________________________________________________________ (V&) ̀18.Whodidthechild(_ren_)livewithwhenyouseparated? ).(+ ̀1.me__________2.partner____________3.bothXS XXX=___________ +*-   # XXS:V#u .,0 ЇFamilyMediationCentre#u`#XS X#X=X XXS)`#  j`  ӀOff-SiteIntake/ScreeningForm  ^ paӀ  J Ѐ19.Whoarethechild(_ren_)livingwithnow? 6 ̀1.me______2partner________3.both_____4.other______  ̀20.Atthepresenttime,withwhomareyouliving?(circleanythatapply)    Ѐ   Ѐ l  Ѐ1.newpartner2.parents#}XX=a#X=X} X  ̀3.otherrelative4.friends#}XX=c#X=X} 0n  ̀5.alone6.other(pleasespecify):#}XX=Kd#____________________ F Ѐ X Ѐ ,j Ѐ >| ЀW} TEWThankYou#W TEe##}We#. P ̀Yourmediatorwillmeetwithyoushortlytocompletetheintakeprocess.... > ,,}IntakefirstsectionJan01#},,f#