First Name: (required)                 

Middle: (required if you have one)

Last Name: (required)                  

Suffix:                                  N/A Sr. Jr. I II III M.D.   

First name by which you wish to be addressed:  (required)    

Your age:             (required)    Age 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70           Your Date of Birth: (required) Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

Your spouse's age: (req'd)      Age 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70     Spouse's Date of Birth: (required)  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993

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)

             Area Code        Number

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)        - Selection Required - Some High School High School Graduate Technical School Some College Bachelors Degree Masters Degree PHD MD OD DC

Current Occupation: 

Company: 

Your annual Income: (required)    $

What do you believe to be your spouse's 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:     

On what date did you and your current spouse get married? (required)   Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012  

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:           Jan Month Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

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

Please list all children, regardless of age.

Child 1:                              

Name                Gender:  Select Boy Girl   

Date of Birth  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011     We call this child by the name of:

Child 2:   

Name                Gender:  Select Boy Girl  

Date of Birth  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011     We call this child by the name of:

Child 3

Name                Gender:  Select Boy Girl  

Date of Birth   Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011     We call this child by the name of:

Child 4:

Name                Gender:  Select Boy Girl

Date of Birth  Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31     Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011    We call this child by the name of:

Child 5:

Name               Gender:  Select Boy Girl

Date of Birth    Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec   Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011    We call this child by the name of:

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

When people decide to mediate, they usually do so to save money, time, and avoid going to court.  Other than these reasons, why do you wish to mediate?

What are your priorities when you mediate?  In other words, how do you want to share the kids?  Do you wish to sell/keep/stay in the marital home?   What do you want out of the settlement?  What about retirement funds?  Debt?  Alimony?

Priority

    1     

    2     

    3     

    4     

    5     

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 - My spouse found you Google Search Yahoo! Search Bing search MSN Search Other Internet Search Engine Therapist Referral Employer Referral Friend Referral EAP Referral Yellow Pages Online CharlotteMommies.com Other Professional (Dr, Lawyer, CPA, etc.) Other    

Name of person referring you to Carolina Divorce Mediators  (if applicable)