First Name: (required)            Middle: (required if you have one)

Last Name: (required)            Suffix:           N/A Sr. Jr. I II III M.D.   

Name by which you wish to be addressed:  (required)    

Age:   (required)            Date of Birth:   (required)        

Address:   (required)

Street Address:   

City:       State:         NC SC GA VA TN WV KY         Zip Code:        

Telephone Contact Information:  (at least one contact number where a message may be left)

Home:             Okay to leave a message?      Yes     No  

Work:              Okay to leave a message?      Yes     No  

Cell:                Okay to leave a message?      Yes     No  

Fax:                Okay to send a private fax?     Yes     No  

Email address where you wish to receive private correspondence concerning your mediation:  (required)

Highest Level of Education you attained:  (required)   - Make Selection - Some High School High School Graduate Some College Associate Degree (2 year) Bachelors Degree (4 Year) Masters Degree PHD MD  

Current Occupation: 

Company: 

Annual Income: (required)    

Have you ever been married before this marriage?   (required)        No Yes

Are you making child support payments to another person of a previous relationship?  (required)    No Yes

Have you hired an attorney for this divorce?  (required)      - Make Selection - I spoke to one, but have not hired one. I have hired an attorney I have NOT hired an attorney.

If yes, provide name:      Phone: 

On what date did you and your current spouse get married?  (required)          

City:  (required)       State:  (required)      Country: 

County in which you were married:  (required) 

What are your living arrangements?  (required)

  - Make Selection - We are living in separate residences. We are living in the same residence. We are in the same residence, but consider ourselves to be separated. I will place some comments in the Additional Information section below

Date you and your spouse began living in separate residences:  

Minor Children of THIS marriage (please provide FULL legal names):

First name:                Middle Name:            Last Name:            Date of Birth         We call this child:

Please answer the following questions (All responses are confidential):

The initial decision to separate/divorce was      - selection required - mutual made by me made by my spouse

                                                         Agree                Agree               Disagree            Disagree

Statement                                         strongly           somewhat           somewhat           strongly

I have no desire to reconcile.                                                                            

I do not blame my spouse for

our separation/divorce.                                                                                    

I wish to stay on good terms

with my spouse.                                                                                             

I wish to remain an active parent

for my children (if applicable).                                                                           

I wish that my spouse remains

an active parent for my children.                                                                       

(if applicable).

My spouse is a good parent.                                                                            

I am a good parent.                                                                                         

I understand my/our financial

situation.                                                                                                        

Alcohol or drug abuse is not an

issue in our relationship.                                                                                  

Violence is not an issue in our

relationship.                                                                                                    

Infidelity is not an issue in our

relationship.                                                                                                    

I believe that we will reach a fair

agreement in mediation.                                                                                   

Additional Information - Use this area to tell us about any other information that is meaningful to you. Examples might be explanations to questions above, roadblocks to your discussions, high conflict subject areas, or anything else that you believe is important. Please be as complete as possible.

Where did you hear about Carolina Divorce Mediators?  (required)

  - Please Select - Google Search Therapist Referral Yellow Pages Directory Yellow Pages Online Divorce Source Friend Referral Yahoo! Search MSN Search Other Internet Search Engine Other