INTAKE FORM

Instructions

1. • Please fill out and submit at least 24 hours prior to your individual intake session. You may schedule that appointment here.

   • Where a response is required but the answer is “none” or “not applicable,” please simply indicate “None” or “N/A.”

   • Individual payment of $185 is required upon submission. 

Thank you—we look forward to helping you!

ALL ANSWERS CONFIDENTIAL AND TO BE USED SOLELY BY MEDIATOR FOR PURPOSES OF YOUR MEDIATION.

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AT LEAST ONE PARTICIPANT MUST BE A RESIDENT OF THE STATE OF ILLINOIS.

Today's date *

Name *

First

Last

Email *

Email

Confirm Email

Permission to email *

• Yes, I give R.I.S.E. permission to email me.

Age *

Date of birth *

Gender *Select…MaleFemaleOther / prefer not to say

Mailing address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Mobile phone *

Is it okay to text you at this number? *Select…YesNo

Is it okay to leave a voice mail at your mobile number? *Select…YesNo

Home phone

Is it okay to leave a voice mail at your home number?Select…YesNo

Work phone

Is it okay to leave a message at your work number?Select…YesNo

Please indicate any additional note or request regarding contact preferences.

Name of other primary mediation participant (family member or spouse). *

First

Last

Relationship of primary participants *

Additional participant(s)

Do you expect anyone else to participate in this mediation, other than you and the partner named above? Please list any such family members or professionals (and their role or relationship) here.

Please describe the matter to be mediated. *

Are both/all primary participants residents of Illinois? *Select…YesNo

Please explain. *

Is this a divorce or separation matter? *Select…YesNo

DIVORCE OR SEPARATION SECTION

Legal status *

If married, please indicate whether divorce or legal separation has been initiated with the court. If so, please describe the case and include (1) which partner filed, (2) date of filing, and (3) which county has the case.

Illinois county where case is pending or may be filed. *

Are there children (minor or adult) from this relationship? *Select…YesNo

Name *

Gender *Select…MaleFemaleOther / prefer not to say

Birthdate *

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Children from the relationship (continued)

Please use this space to list any additional children. You may include anything else you feel is relevant.

Are there children (minor) from previous or external relationships? *Select…YesNo

Name *

Gender *Select…MaleFemaleOther / prefer not to say

Birthdate *

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Name

GenderSelect…MaleFemaleOther / prefer not to say

Birthdate

Children outside of the relationship (continued)

Please use this space to list any additional children. You may include anything else you feel is relevant.

Is there any chance you are pregnant? *

You may use this space to add anything you’d like.

Length of marriage or union *

Date of marriage or union *

Place of marriage or union (county, state; country if not USA) *

Current employment status *Select…Employed (self)Employed (other) full-timeEmployed (other) part-timeStudentHomemakerUnemployed (seeking)Unemployed (not seeking) / Other

Please explain. *

Please describe. *

Employer *

Work address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Time at employer *

Time self-employed *

Position or title *

Annual income from employment *

Include bonuses, if any.

Annual revenue *

Annual income from self-employment *

Do not include money poured back into the business.

Anything you would like to add or clarify regarding employment?

+++END OF DIVORCE/SEPARATION SECTION+++

Thank you! Please continue with the next question.

Have you tried mediation before? (On a computer, pressing 'Shift" should enable you to select more than one.) *Select…Yes, in this matterYes, in another matterNo

Please describe the previous effort(s) in this matter, including progress or outcome. *

Briefly describe your mediation experience outside of this matter. *

Other information or concerns you would like to share? (Remember, everything shared here is confidential, including from the other participant/s.)

Please use this space to identify anything else it would be helpful for us to know.

Have you retained an attorney in connection with this matter? *Select…YesNo, and don't plan/want toNo, but plan/want toNo, but I'm open to it

Please explain. *

Name of firm *

Attorney name *

Attorney address *

Address Line 1

Address Line 2

City

— Select state —AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

How did you hear about us? *

Please specify name or referral source. This information is truly helpful!

Did you review our website before reaching out? *Select…YesNo

Emergency (non-participant) contact for mediation sessions *

First

Last

Emergency contact's phone *

Emergency contact relationship *

Intake Total

Price: $185.00

NOTE:  Please save your form (using the “Save and Resume Later” link below) prior to submitting payment, to forestall unforeseen payment issues resulting in your having to start over.

Stripe (credit or debit card) or Google Pay *

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