313 East 7th St, Logan, IA. Suite #1. 51546

Phone: 402-580-1147

Email: HelpingHandMediation@Gmail.com

Website: HHMediation.com

Personal Data and Information for Mediation

1. Name _________________________________________ Phone:______________________

Home Address ________________________________________________________________________________

2. Other Party’s Name_______________________________ Phone:______________________

Home Address _______________________________________________________________________________

3. What is the case number and the county where any action is pending?

Case # _________________________________ County _________________________________

4. Date of Marriage (if married) ________/________/______

Date of Separation _______/________/_______

5. Children of Current Marriage / Relationship?

Full Name Age Date of Birth Residing With

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Do you anticipate a dispute about custody of children? Yes No

7. Do you have any court dates pending? _________________ When?____________________________________

Is this a modification of a prior decree or court order? Yes No

8. Do you have an interest in reconciliation? Yes No

As far as you know, does your spouse / other party? Yes No

9. Are you presently seeing a counselor or therapist? Yes No

If Yes, Individual Joint Family Children

10. Have you previously seen a counselor or therapist? Yes No

If Yes, Individual Joint Family Children

11. Are you employed? Yes No

If Yes, Employer _______________________________Phone ____________________________

Address_________________________________________________________________________

Job Title ____________________________ Nature of Job__________________________

Date Hired __________________ Current Salary /Wage $ ________________________

12. Is your spouse / other party employed? Yes No

If Yes, Employer _______________________________ Phone ____________________________

Address__________________________________________________________________________

Job Title ____________________________ Nature of Job_________________________________

Date Hired __________/__________/_________ Current Salary / Wage $ _________________________

13. Do you presently have an attorney? Yes No

If Yes, Name ___________________________ Email______________________________ Address______________________________ City / ZIP ____________________________

FAX: ___________________________ Phone: ___________________________________

14. Does your spouse / other party presently have an attorney? Yes No

If Yes, Name ___________________________ Email______________________________ Address______________________________ City / ZIP ____________________________

FAX: ___________________________ Phone: ___________________________________

15. Is there anything you would like me to know about your situation; about you?; about the other party?; about your family?

16. Are there any “no contact orders” in place between you and your spouse / other party? Yes No

If yes, please explain: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

17. Do you feel afraid or threatened by your spouse / other party for any reason? Yes No

If yes, please explain:

18. Has your spouse / other party... Hit you? Threatened you? Used physical force against you?

19. Have the police been called to your home? Yes No

20. Do you feel you can express your concerns / position at mediation in front of your spouse / other party?

Yes No

If no, please explain:

21. Please sign and date:

Signature __________________________________________ Date: __________________

- General Mediation Information Sheet –

Please fill out and bring to mediation for your own consideration

PREPARE AND BRING ANY DOCUMENTATION NECESSARY!

In preparation for mediation, please think about the following items. If you can, list out some start times and end times for your use, and the use of the mediator. Think about how holidays are observed in your family, and how they are observed in the other parent's family (if you know).

Case No.: ______________________ Legal Custody: Sole?_______ Joint? _______

Primary Physical Care: Shared_____ Mother ____ Father____

VISITATION (Think about Days, Times and length also)

Weekends: ______________________________________________________

Weeknight(s): __________________________________________________

Summertime: ____________________________________________________

HOLIDAYS:

New Year: ______________________________________________________

Easter: ________________________________________________________

Spring break: __________________________________________________

Mother’s Day: __________________________________________________

Memorial Day: __________________________________________________

Father’s Day: __________________________________________________

Independence Day: ______________________________________________

Labor Day: _____________________________________________________

Halloween: _____________________________________________________

Thanksgiving: __________________________________________________

Christmas: _____________________________________________________

Other Significant days? ________________________________________________________________

- General Mediation Information Sheet -

Think about and prepare for the following items, consider how you would like them handled.

· Weekend visits during summers- uninterrupted period of vacation?

· Ending weekend visits in night before holiday

· Cancellations and make-ups

· Notice for summertime

· Children’s birthdays

· Parent’s birthdays

· Transportation- exchange point (if needed).

· Need to adjust visitation for age or special needs of child?

· If needed, each parent shall have an appropriate car seat.

· Reasonable notice if out of state trip is planned.

· Clothing, toys, books sent with child shall be returned; some kept at both parent's; special ones go back and forth.

· Extracurricular activities and other parent’s time

· Telephone access- times- phone cards- other parent shall not listen in or record telephone conversations with the other parent.

· Sharing of schedules, schools, sports, church, scouts, etc.

· Sharing of Records

· Religious Instruction and Participation

· Information must be exchanged and kept current:

· Address of residence

· Phone number

· Name and address of all employers

· Name and address of all day care providers

· Names and addresses of schools, doctors, dentists, and counselors.

§ Speak with your legal representation prior to the mediation. You may request them to be available, present, or answer all questions you may have before going to mediation.

§ Additionally, it is best to prepare yourself with all documents, ideas, positions, and wants from resolution and bring them with you to the mediation.

§ PREPARE AND BRING ALL IMPORTANT DOCUMENTATION!

§ Each parent in mediation starts with a short statement about what issues and concerns are important to them. In preparation for mediation, take some time to think about what you want to say.

Ground Rules for a Successful Mediation

(This is a guideline and an abridged list of items to review and assist you prepare for your mediation.)

v Follow the instructions of the mediator.

v PLEASE DON’T INTERRUPT. Each person has a right to be heard completely. You will get your turn. If you have something you feel you must say, make a note and wait your turn.

v You are a decision maker!

v Participate with open and honest communication and self-determination.

v Treat the other party with respect.

v You have the power to accept and reject any offer of resolution made by the other party. You may also seek legal counsel at any time. (see contract)

v One person speaks at a time and identifies the issues that are important for him or her to discuss as well as what he or she views the conflict to be.

v Each person should be prepared with some ideas for solutions to any problem/s.

v You may ask for a break at any time.

v Listen to what others say about the situation as well as how they felt about it and what they thought about it.

v Work hard to understand what the other person is saying, even if you need to take notes.

v Be prepared that the other party may not show and isn’t required to be emotional.

v Be prepared to explain the other person’s point of view if you were asked to.

v Be prepared to try to understand the other person’s feelings, thoughts and needs.

v Be prepared to explain your feelings, thoughts and needs.

v Be prepared to try to understand the other person’s feelings, thoughts and needs both now and in relation to any previous interchange you may be discussing.

v Be prepared to consider that you may have been mistaken about something, have been missing information, or may have made an incorrect assumption.

v Be aware of time limits.

v Be prepared for some adjustments in your behavior if any are requested.

v Be prepared to ask or to possibly be asked of something - More of something - Less of something - Something entirely new or instead of something

Personal Data Information

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