Fill out Intake Form for Mediation Services
in St John’s

Fill out Intake Form and submit to Jazz Mediation. Once an Intake Form is received from both parties, a confidential Mediation Assessment is booked with each party individually.

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Mediation of family law disputes in St. John’s, Newfoundland by a highly trained Family Mediator.


Intake Form

This document is strictly confidential, and is submitted as part of a confidential (closed) mediation process. It will be read only by the mediator and our staff. Once an Intake Form is received from both parties, a confidential Mediation Assessment is booked with each party individually. Each party pays a flat fee for Mediation Assessment.


Are there any days that work best for you?

MonTuesWedThursFri

What is best way to reach you?

Home PhoneCell PhoneWork PhoneEmail

Are there any days that do NOT work for you?

MonTuesWedThursFri

Are mornings or afternoons best for you?

MorningAfternoonEither


Employment Information

Relationship Details

Other Party Information

Are there any legal reasons that prevent you from communicating directly or indirectly?

YesNo

Is there a Police File?

YesNo

Is there a Social Services File?


Separation Information

What are the issues for mediation? (Check all that apply)
Parenting PlanChild SupportSpousal Support (or Partner Support)Division of PropertyOther


Do you have any concerns about yourself?

Emotional Well-BeingPhysical HealthMental HealthCapacity to Make DecisionsAnger ManagementAlcohol or Drug Use

Do you have any concerns about the other party?

Emotional Well-BeingPhysical HealthMental HealthCapacity to Make DecisionsAnger ManagementAlcohol or Drug Use


Do you want Jazz Mediation to send an Invitation to Submit an Intake Form to the other party?

YesNo


Is there anything else you think it would be helpful for the mediator to know?
Is mediation right for you?

Get in touch today and let’s discuss your options.


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