CONFIDENTIAL DIVORCE MEDIATION QUESTIONNAIRE Name of person filling out this form * First Name Last Name Do you know what action you are seeking? Divorce? Legal Separation? To be determined? Have you and your spouse been residents of California for at least six months and residents of your current county for at least three months? * Date of Marriage * Date of Separation? If you do not know what your date of separation is yet, leave this field blank and we will discuss in our first session. If you know who wants to be the person requesting the divorce list that information here. Do you expect to pay or receive spousal support? * If a spouse would like her maiden name restored upon completion of your divorce, please list it here. Are either of you currently in the military? Your legal name (including middle name) * Your birthdate * Your age * Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Your Social Security Number (only required if you have children) Your Driver's License Number Your employer How many hours do you work per week? Employer's Address (including city, state, and zip code) Employer's phone How long have you been with this company? Are you not employed outside the home? If so, for how long? Are you retired? What is your highest level of education? If you went to college or graduate school, what degree did you earn? * List your work history What is your gross income (before taxes)? * If you receive commission, how much? How is your commission determined? If you receive bonuses, how much? How are they awarded? If you receive stock options, how much? How are they awarded? Do you receive income from self-employment? How much? Do you receive pension/retirement/disability income? If so, how much? Do you have health/dental/vision insurance? Who is paying for it? How much does it cost? * Spouse's Legal Name * Spouse's birthdate * Spouse's age Spouse's email * Spouse's phone Spouse's Social Security Number (only required if you have children) Spouse's Driver's License Number Spouse's employer Spouse's job description How many hours a week does your spouse work? Spouse's employer's address Employer's phone Years with this company Is your spouse not employed outside of the home? If so, for how long? Is your spouse retired? What is the highest level of education your spouse has? If they went to college or graduate school, what degree did they earn? What is your spouse's monthly gross income (before taxes)? * If your spouse receives commissions, how much? How are they determined? If your spouse receives bonuses, how much? How are they determined? If your spouse receives stock options, how much? How are they awarded? Does your spouse receive income from self-employment? If so, how much? Does your spouse receive any pension/retirement/disability income? How much? Does your spouse have health/dental/vision insurance? If so, who pays for it? How much does it cost? Does anyone in the family have a medical condition, special need, or other special circumstance that you would like addressed? Are there any minor children from this marriage? * Please provide children's names (including middle names), birthdate, age, gender, and city of birth) Please provide your children's Social Security Numbers Were any of your children born before the marriage? If yes, please provide the children's names. Are either of you parenting minor children born before the marriage? If yes, please provide the children's names. Have you lived at the same address with all children for the past 5 years or more? If not, please provide the last 5 years of residential history for each of your minor children. Are there any court proceedings of any kind currently ongoing that involve any of your children? If so, please provide details. Are any children currently on prescription medication and/or under ongoing medical, dental, or orthodontic care? Are any children in daycare or after-school care so a parent can work? If so, what is the cost? Are your children participating in extra-curricular activities, tutoring, clubs, second language learning, or other programs? If so, please provide details including the costs and seasons of the activities. Who can I thank for your referral? And/or how did you find PxP Mediation? Thank you!
