Private Mediation Counseling / FCS Preparation Form

First name*

Last name*

Mobile phone number*

Email*

Street address

City

State & ZIP code

Today's Date*

Year/Month/Day

How did you find me, or who may I thank for referring you to me?

What are you wanting to consult with me for?

Prep for Family Court Services/Mediation

Private Party Mediation Counseling

FCS/Mediation Date and Time (If applicable)

Year/Month/Day

Who is your attorney?

Your Court Case #:

Next Court Date

Year/Month/Day

Judge assigned to case:

Other parent's name:

Other parent's attorney:

How long have you been separated or divorced?

Names and ages of child(ren) *

Has Minor's counsel been assigned to your child(ren)?

Yes

Regarding the child(ren): Please enter any information you think might be helpful for me to know.

For Visitation - Do you currently have a

Court Order for the current schedule

Mutually agreed upon visitation schedule

No visitation at all

Other

Current Visitation Percentage and Schedule

Are you happy with the current custody & visitation order?

Yes

Not Sure

Your Concerns:

Allegations:

Information: