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Intake Form

Case No.
Appointment Date:
Full Name:
Birth Date:
Phone:
Mailing Address:
City:
State:
Zip:
Email:
       
Children's Names and Birthdays
Child Name: Birth Date:
Child Name: Birth Date:
Child Name: Birth Date:
Child Name: Birth Date:
Child Name: Birth Date:
           
List other people who live in your home:
Name:
Birth Date:
     
Name:
Birth Date:
     
Name:
Birth Date:
     

Please select any and all of the following that apply to you, the other party or the children now or in the past:
Order of Protection
Registered Sex Offender
Child Protective Services
Bankruptcy
Child Abuse or Neglect
Alcohol or Substance Abuse Concerns
Police Contact/Involvement
Mental Health Issues
Arrested
Receive or Applied for Cash Assistance or AHCCCS
Convicted of a Felony
    

Please select any and all of the following that apply to you:
I am afraid to participate in the mediation conference with the other party.
I am the victim of emotional, physical or verbal abuse.
I am represented by an attorney.
 
Attorney Name
  Atty. Address
  Atty. City
  Atty. State
  Atty. Zip
  Atty. Phone
I have concerns regarding the child(ren) or the other party that I am afraid to discuss with the other party present.
    

Personal identifying information will be kept confidential, and is for internal use only.
 
By inserting my name here, I hereby declare under penalty of perjury and under the laws of the State of Arizona that the foregoing is true and correct.

Type your name as your signature:

Signature of person completing this form

Date:


 

 
 

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