Personal Information Date
Name Age Address Zip Email Telephone: Daytime Evening Employer Occupation Referred by Marital Status (mark all that apply)Never married Widowed Divorced Married Yrs Separated months Spouse’s name Age Names and ages of your children:Describe any significant health issues that might impair your ability to effectively participate in mediation:Do you have an attorney? select oneYesNo Attorney's Name: Attorney's Address: Has a legal action been filed or is one likely to be filed in this situation? select oneYesNo (describe below)Have you received advice from anyone else regarding this situation? select oneYesNo(describe below) Religious Background Religion: NoneChristianJewishAgnosticOther Do you believe in God? YesNoUncertain How often do you pray to God? DailyWeeklyIrregularlySeldomNever What church do you attend? Pastor Address Phone Member? YesNo How often do you attend church? weekly Irregularly Seldom Never Church leadership positions you hold or activities you are involved in: How often do you read or study the Bible? DailyWeeklyIrregularlySeldomNever What is your view of the authority of Scripture? Who has the most influence on your religious or spiritual life? Please give names and relationship.Other Person in conflictIf there is more than one other person, please mark the box below and provide the same information about them on additional sheets. Name Relationship How long Mailing address Zip Email Telephone: Daytime Evening Fax Church Attorney Employer Occupation This person’s religious orientation and commitmentInformation on Your Problem or DisputeBriefly describe your problem or dispute (you can give us more detailed information later during an interview): What have you done to resolve this problem or dispute? What issues or questions do you want to have resolved or answered? What do you want us to do? If this is a legal matter, what are you asking for? (Include dollar amount, if any) Other information we should know?
Salem Alliance Church | 555 Gaines St. NE, Salem, OR 97301 | 503.581.2129