Intake Form

Case Number
Appointment Date
Full Name
Birth Date

Phone Number
Address

City
State

Zip Code
Email Address

Children's Names and Birthdays


Child Name
Child DOB
Child Name
Child DOB
Child Name
Child DOB
Child Name
Child DOB
Child Name
Child DOB

List other people who live in your home


Name
DOB
Name
DOB
Name
DOB

Please select yes or no to the following that apply to you, the other party or the children now or in the past


  Order of Protection

  Registered Sex Offender

  Child Protective Services

  Bankruptcy

  Child Abuse or Neglect

  Alcohol or Substance Abuse Concerns

  Police Contact/Involvement

  Mental Health Issues

  Arrested

  Receive or Applied for Cash Assistance or AHCCCS

  Convicted of a Felony


Please select yes or no to the following that apply to you


  I am afraid to participate in the mediation conference with the other party

  I am the victim of emotional, physical or verbal abuse

  I have concerns regarding the child(ren) or the other party that I am afraid to discuss with the other

  I am represented by an attorney


Attorney Name
Attorney Phone
Attorney Address
Attorney City

Attorney State
Attorney Zip Code

Personal identifying information will be kept confidential, and is for internal use only.


By inserting my name here, I hereby declare under penalty of purjury and under the laws of the State of Arizona that the foregoing is true and correct
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