Fresno Pacific University
Mediation Services Family Division
INTAKE FORM
What is this form for? You and your spouse have been referred to FPU Mediation Services
Family Division for help with developing a (MSA) Marital Settlement Agreement. Professionals
in our family division are trained as mediators and on other topics related to family court cases,
including domestic violence. The information collected on this form will be used to help the
mediator decide how to best help you with your particular case. If an agreement is reached you
will receive a written copy of the (MSA) Marital Settlement Agreement to file with the court.
Today’s date___________ Case Number#___________________ Next hearing date__________
BACKGROUND INFORMATION
Husband’s Information
Full Name________________________________Date of birth ___________________________
Address______________________________ City/State/Zip_____________________________
Home Phone______________________ Work Phone__________________________________
Cell Phone_________________________ Email Address________________________________
Occupation/ Annual Income_______________________________________________________
Are you represented by an attorney in this case? _____ Yes ____No
If yes, please provide the attorney’s name and contact information below: Name, Address,
Telephone, Email, and Fax Number_________________________________________________
_____________________________________________________________________________
Wife’s Information
Full Name________________________________Date of birth ___________________________
Address______________________________ City/State/Zip_____________________________
Home Phone______________________ Work Phone__________________________________
Cell Phone_________________________ Email Address________________________________
Occupation/ Annual Income_______________________________________________________
Are you represented by an attorney in this case? _____ Yes ____No
If yes, please provide the attorney’s name and contact information below: Name, Address,
Telephone, Email, and Fax Number_________________________________________________
______________________________________________________________________________
Have you been provided and read the written mediation brochure materials? _____Yes ____No
How did you hear about us?______________________________________________________
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Children involved in this case
First name
M.I.
Last Name
Age
Date of birth
_____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please provide the following dates, if applicable, as well as you can estimate:
Date of marriage: _________Dates lived together: __________Date of separation: __________
Related cases: It is helpful to know if your family (you, the other parent, and children/child)
has been involved or is involved in other court cases. If there are other cases related to this
one, please let us know:__________________________________________________________
_____________________________________________________________________________
Do you have any concerns about mediating (talking about your case and plans for parenting
your children) with the other parent in the same room?
_____Yes _____No
Do you have court orders for ____custody ____visitation____ spousal support?
Have you been to mediation with the other parent before?
______Yes ______No
Domestic Violence questions: Mediators need to know about your case so that your
appointment is as helpful to you as possible. Please answer the following questions:
Have either you or the other parent said that there are concerns about family violence?
_____Yes
______No
Has a request for a restraining order been filed within the last five years?
Is there a restraining order in place right now?
______Not Sure
______Yes ____No
______Yes ______No
Do you have any concerns about your safety around the other parent?
______Yes _____No
If yes, to question #4 the mediator will talk with you about your concerns. Is there anything
you would like to briefly write to the mediator about this now?
______________________________________________________________________________
Your case may be one where a “separate session” must be provided. If there are
allegations or a history of domestic violence, or if there is a restraining order in your case, you
have the right to meet with the mediator without the other party upon request (“separate
session”). In a case with allegations or a history of domestic violence, even if you do not ask for
a separate session, the mediator will speak with each parent separately before meeting with
you together (or during or after if the domestic violence comes up during the session). A
request for a separate session is not viewed as evidence of lack of cooperation.
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Are you asking for a separate session at this time?
_____Yes _____No
If you are unsure about whether you need to meet separately, would you like to
speak with the mediator privately about the mediation process? ____Yes _____No
Support person: If a restraining order has been issued to protect you, a support person is
allowed to go with you to any mediation or orientation session, including separate sessions.
However, the mediator may exclude a support person if the support person participates in the
mediation, acts as an advocate, or if their being there interferes with mediation.
PROPERTY DISTRIBUTION
Do you own a home and /or a vacation home?
_____Yes _____No
Is there a mortgage on the property?
_____yes _____No
Do you own a car(s)?
_____yes _____No
What do you feel needs to be discussed in mediation? (Check as many as applicable)
_____ Property
_____ Authority/Decision-making
_____ Spousal Support
_____ Creating peaceful communication
_____ Following the court’s order(s) OTHERS_________________________
How to prepare for Mediation: see our Checklist below and bring all that applies to
mediation
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Preliminary Disclosure Documents- should be filled out at the time of filing with the court. If not, they
are available on the court’s web site.
Real Estate Documents- If either of you own a home or other real property, bring a document that gives
a legal description of the property (a grant deed from the recorder’s office or/ and a recent statement
from the mortgage company will be sufficient.
Vehicle Registration- Please provide the vehicle identification number (VIN), make, model and year of
each vehicle.
Retirement/Pension account information- Be prepared to tell us who the retirement account is with,
type of account, Administers name and the most current statement of the account.
Debt information- for any sole or joint debt accounts, bring the name of the creditor, account number,
and balance owing. This includes credit cards, student loans, vehicle loans and personal loans.
Business/Partnership information, including the legal name of the business or partnership. Any
information regarding stocks or bonds as well.
Child information- all current orders regarding child custody and/or support.
Court Documents: ALL documents filed related to divorce or legal separation.
Confidentiality
Mediation sessions are private and the mediator may not share information from those
sessions with just anybody. You should not assume information you share separately with the
mediator may be kept confidential from the other party, however, you may tell the mediator if
there is information you are providing that may put you at risk if it is shared. Mediators and
staff must make reasonable efforts to keep residential addresses, work addresses, and contact
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information-including but not limited to telephone numbers and e-mail addresses-confidential
in all cases and on all Mediation Services Family Division documents.
Note: Please provide information for all sole and joint accounts
What if we reach an agreement?
Copies of your Marital Settlement Agreement will be provided to you and submitted to the
court only after all parties (including their attorneys) have signed the document and all fees are
paid.
What if we do not reach an agreement?
Mediation is a voluntary, confidential, and self-determining process. If an agreement could not
be reached the parties are free to seek other alternatives or return to court for the judge to
decide. The Mediator will not make recommendations to the court regarding your case or
reveal information to your attorney’s. The only communication between the mediator and an
attorney of record will be a copy of a signed agreement.
What information goes to the judge?
Mediation will end with either a written parenting plan of the parties' agreement or a
mediator's
Notification to the court of a non-agreement.
What information goes to people outside the court?
There are certain situations in which mediators are required or permitted to reveal information
without
your permission. They are not required to inform you of their actions in this situation. If you
threaten violence to another person, the mediator may be required to inform the intended
victim and the appropriate law enforcement agencies. If you are likely to harm yourself unless
protective measures are taken, the law may permit the mediator to take appropriate actions to
ensure your safety. If the mediator has reasonable cause to suspect abuse and/or neglect of
children, elderly or dependent adults, or if such is reported to the mediator, that mediator may
be required by law to report to an appropriate protective agency and/or the police.
_________________Please answer the following after the Intake process_______________
Do you have a better understanding of the mediation process?_____Yes ____No
Was this intake helpful to you?
____Yes ____No.
Who was your mediator? ________________________________________________
Additional Comments___________________________________________________
______________________________________________________________________
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