Personal Information

Date:
Name: Age:
Mailing Address: Zip:
Email:
Telephone:
Employer: Occupation:
Referred by:
Marital Status(mark all that apply):
Never married
Widowed
Previously Divorced
Now Married:Yrs
Now seperated:Yrs
Spouse's name: Age:
Please give the names and ages of your children:

Briefly describe any significant health issues that might impair your ability to effectively participate in mediation:

If you have talked or intend to talk with an attorney about your problem, please provide the information:
Attorney: Firm:
Address:
Has a legal action been filed or is one likely to be filed in this situation? No Yes

Have you received advice from anyone else regarding this situation?
No Yes

If it is possible, as far as it depends on you, live at peace with everyone.
Romans 12:18

Religious Background

We found that a person's religious background can have a significant impact on how he or she deals with conflict. In order for us to be sensitive to your personal convictions, it is helpful for us to receive the following information at the outset of the conciliation process.

Religion:
None Christian Jewish Agnostic Other
Please describe your religious upbringing:
Do you believe in God? No Yes Uncertain If yes or uncertain:
Do you believe that when you die you will be with God eternally? No Yes Uncertain
Why?

Have there been any recent significant changes in your spiritual life? No Yes (describe below)

If you currently belong to or attend a church, please provide the following information:
Church: Pastor:
Address: Phone:
Are you a member? No Yes, since
How often do you attend church meetings?
Times per week Irregularly Seldom Never
Desribe any church leadership positions you hold or activities you are involved in:

How often do you read or study the Bible? Daily Irregularly Irregularly Seldom Never
I don’t know enough about the Bible to have an opinion.
It is a book that contains helpful principles that I am free to follow or disregard as I think best.
It is a book that was inspired by God and that contains helpful principles and instructions that I should follow unless I believe there is a good reason to do otherwise.
It is a book that was inspired by God and that contains helpful principles, instructions, and commands that I should follow regardless of my feelings or preferences.
Other:
Who, if anyone, has the most influence on your religious or spiritual life? Please give names and relationships.

Information on the Other Person

Please provide as much information as possible regarding the other person in this dispute. If there is more than one other person, please mark the box below and provide the same information about them on the back of this sheet.
Name:
Relationship with you: For how long?
Mailing Address: Zip:
Email:
Telephone:
  • Daytime:
  • Evening:
  • Fax:
Church: Attorney:
Employer: Occupation:
Please provide as much information as possible on this person’s religious orientation and commitment:

Information on Your Problem or Dispute


Before you complete this section, please read all six questions so that you can see how to organize your answers.
  1. Briefly describe your problem or dispute (you can give us more detailed information later during an interview):
  2. What have you done to resolve this problem or dispute?
  3. What issues or questions do you want to have resolved or answered?
  4. What do you want us to do? What are your hopes and expectations in coming here?
  5. If this is a legal matter, what claim or remedy do you seek? (Include dollar amount, if any)
  6. Is there any other information we should know?