Fill - Free fillable MEDIATION QUESTIONAIRE Revised 03 03 17 (County of Indiana) PDF form

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_________________________________, § IN THE COURT OF COMMON PLEAS

Plaintiff § OF

Vs. § INDIANA COUNTY, PENNSYLVANIA

_________________________________, §

§

Defendant §

§ NO. _____________________

§

MEDIATION QUESTIONNAIRE

I, __________________________________________, the Plaintiff ( ) or Defendant ( )

(Please Print Name)

(Check one) undersigned below, hereby certify that the following information is true and correct to

the best of my knowledge and belief.

__________________________________ ____________________, 20_____

(Please Sign Name) (Date)

I am ( ), am not ( ) represented by an attorney. My attorney’s address and telephone number is as

follows:

_______________________________ Esquire

_______________________________ (Address)

_______________________________

_______________________________ (Phone including Area Code)

_______________________________

My address and telephone number is as follows:

_______________________________

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Date of birth:___________________________________________________________________

Educational background: _________________________________________________________

Brief description of current residence: ______________________________________________

______________________________________________________________________________

Subject children of this action:

Name Date of Birth Age Grade Level School

________________________________________________________________________________

Other children in household:

Name Age Relationship to Party

________________________________________________________________________________

Marital/Cohabitation History:

Date of Marriage or Cohabitation: (if applicable) ________________________________________

Date of Separation: _______________________________________________________________

Cause of Separation: (brief explanation) ______________________________________________

Date of Divorce: (if applicable) ______________________________________________________

Is a divorce action pending? ________________________________________________________

Current Marital Status/Living Arrangements: ___________________________________________

________________________________________________________________________________

(i.e.): Remarriage or Cohabitation – provide name of new spouse or cohabitant

Procedural History:

Verbal Custody/Visitation Arrangements: (Describe arrangement with applicable dates)

________________________________________________________________________________

Written Custody/Visitation Arrangements: (Summarize arrangement and applicable dates)

________________________________________________________________________________

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Orders of Court: (Summarize or Attach, including Orders from foreign jurisdictions and dates of entry)

________________________________________________________________________________

Current Custody/Visitation Arrangement:_______________________________________________

________________________________________________________________________________

Proposed changes in current custody/visitation arrangement: _______________________________

________________________________________________________________________________

Does child(ren) have any special needs? _______________________________________________

________________________________________________________________________________

Have home studies or psychological evaluations been completed? If so, by whom and dates:

________________________________________________________________________________

What is your present employment status?:

( ) Employed ( ) Unemployed ( ) Unable to Work ( ) Other

Do you work in the home? _____yes _____no

Do you work in the town in which you reside? ______yes ______no

If, no, how far do you commute? ________miles.

Does your employment take you out of town? For how long? How often? Explain:

________________________________________________________________________________

Name, Address and Phone Number (including Area Code) of each employer or your own business:

__________________________ ____________________________ ___________________

Name Address Phone #

__________________________ ____________________________ ___________________

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Circle the days you work:

M T W TH F SAT SUN From ______ to ______

Do you work any type of alternating or unusual shifts? Explain:

________________________________________________________________________________

Is your employer ( ) flexible or ( ) inflexible about working around your child custody/visitation

needs?

How long have you worked for this employer? __________#1 __________#2

State your present physical/mental condition:

( ) Good ( ) Fair ( ) Poor

Are you presently under a doctor’s care? Explain your condition:

________________________________________________________________________________

Name of Doctor: ____________________________________________________________

Address: ____________________________________________________________

Phone: ____________________________________________________________

Are you taking any prescription drugs? ______ yes ______ no.

If yes, Name of Drug ___________________ Amount (mg./day etc.) _______________________

Do you drink alcohol? ______ yes ______ no. If so, how much?

______ heavy ______ moderate ______ occasionally

Have you remarried? ______ Are you cohabiting? ______

What is the person’s name? _________________________________________________________

Does he/she have children? If so, what ages, sexes and with whom do they reside?

________________________________________________________________________________

When did you remarry? _______________ When did you begin cohabitation? _______________

Does the other party to this action know your current spouse or cohabitant? ___________________

Explain: ________________________________________________________________________

How long have you known your current spouse or cohabitant? ________ yrs. _________mos.

Do your children know them? _______ For how long? __________

Have you filed in the Prothonotary’s Office a completed Criminal Record / Abuse History

Verification Form according to Pa.R.C.P. 1915. 3-2. Criminal or Abuse History?

No___ / ___Yes = Date Filed: _____________

FACTORS, CONDITIONS AND/OR CONCERNS I CONSIDER VERY IMPORTANT THAT I

WOULD ASK BE TAKEN INTO ACCOUNT BY THE MEDIATOR WHEN ENDEAVORING

TO PROVIDE THE BEST SITUATION FOR THE CHILDREN IN THE ACTION ARE AS

FOLLOWS: [Use extra pages, if necessary]

________________________________________________________________________________

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________________________________________________________________________________

ATTACH PROOF OF PAYMENT OF $150.00 TO THE PROTHONOTARY OF INDIANA

COUNTY OR COPY OF AN APPROVED PETITION FOR IN FORMA PAUPERIS

(INDIGENT) STATUS AND COPY OF CERTIFICATE OF ATTENDANCE OR PROOF

OF REGISTRATION FOR CHILDREN IN BETWEEN PARENT EDUCATION COURSE

AND FORWARD TO:

MATHEW G. SIMON, ESQUIRE

CHILD CUSTODY MEDIATOR

INDIANA COUNTY COURTHOUSE

INDIANA, PA 15701

ALL MATERIALS MUST BE RECEIVED BY THE CHILD CUSTODY MEDIATOR NOT

LATER THAN 7 DAYS PRIOR TO MEDIATION.

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WAIVER OF MEDIATION COMMUNICATION PRIVILEGE

I understand that the Child Custody Mediator will make a report of the

Mediation proceedings to the Court. The Report may be made available to

professionals requested to perform evaluations or provide treatment to the

parties and/or children. The Report may contain information about settlement

discussions, including the final positions of the parties if agreement is not

reached. I waive the privilege of 42 Pa. Con. Stat. Ann Section 5949 in regard to

mediation communications occurring during the Child Custody Mediation

Conference in respect to the Mediator’s Report

_____________________ _________________________________

Date Signature

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