Mediation Information Form

Please take a few moments to complete this private and confidential information form. It is the first step of the confidential mediation process.  The process can only begin when we have received both parties’ information forms.

Once we have received both parties’ information forms, the mediator who is assigned to your case will contact you individually to set up your confidential intake meetings. These meetings are free of charge. During the intake meetings, the mediator will assess if your case is suitable for mediation. Some cases may not be appropriate for mediation.

If you currently have a court date and/or have a court file number, On-Site mediation will be provided to you free of charge for matters that can be addressed in two hours or less.  If you do not have a court date and/or have a court file number, The Ministry of Attorney General subsidizes family mediation fees for off-site mediation. These fees are charged based on each person’s income. Click here for the fees schedule.

We encourage all clients to obtain legal advice before, during and after all mediations.

Your General Information



How long did you date?



Issues to be Mediated (check all that apply)



Has your former partner done any of the following hurtful acts or behaviors? * Please answer YES or NO for each question* If YES, then please check when (before and/or after separating) and how often.

During the last six months prior to separation:

Since you emotionally separated.


Please read and acknowledge your acceptance of the following confidential information which you will be confirmed by submitting the document at the end of this form:
  1. The Mediator and the Parties shall keep confidential all written and verbal information prepared, provided, disclosed, or exchanged during or for the purpose of the mediation.
  2. Notwithstanding the aforementioned, the Mediator, Mediation Service Provider, Information Referral Coordinator (IRC), interns, volunteers or observers, may at their sole discretion, disclose information about the mediation:
    1. To communicate with the Parties, their lawyers or other legal representatives, and third parties retained by a Party, their lawyer, or other legal representative;
    2. Where ordered to do so by law;
    3. Where required to do so by law, including but not limited to obligations to report a child in need of protection; or
    4. Where the information indicates an actual or potential threat to human life or safety.
  3. We acknowledge that our discussions in mediation are only for the purpose of reaching an agreement regarding the issues between us. We agree not to summons or compel:
    1. The Mediator, Mediation Service Provider, Information Referral Coordinator (IRC), interns, volunteers or observers to testify or otherwise participate in any legal proceeding, including but not limited to any court or arbitration hearing; or
    2. The disclosure of any mediation documents. However, documents that are otherwise discoverable or admissible as evidence in a legal proceeding do not become inadmissible or non-discoverable merely because of their use during the mediation process.