Page 82 - Meeting with Children Manual

P a g e | 2 Client Intake Form

Party A File Number ______________________ Colour of Risk_____________

RELATIONSHIP DETAILS:

Relationship De facto duration: __________________ Type  Married
Duration Married duration: __________________  De facto
Married date: __________________  No Relationship
Separation date: __________________  Sibling
Divorced date: __________________  Grandparent
 Parent/Child
 Other
Separation Comments
 Not separated
 Separated informally
 Separated same roof
 Physical separated
 Never together

CHILDREN DETAILS:

Name of Child Date of Birth Age
Name of Child Date of Birth Age
Name of Child Date of Birth Age
Name of Child Date of Birth Age
Name of Child Date of Birth Age

ISSUES FOR MEDIATION:

 Parenting Notes:  Property Notes:

 Communication Notes  Other Notes:

 Legal Action to Date

© Lorri Yasenik and Jon Graham 2016
Private and Confidential
We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
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