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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: ______________________________________________
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Subject children of this action:
Name Date of Birth Age Grade Level School
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Other children in household:
Name Age Relationship to Party
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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: ___________________________________________
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(i.e.): Remarriage or Cohabitation provide name of new spouse or cohabitant
Procedural History:
Verbal Custody/Visitation Arrangements: (Describe arrangement with applicable dates)
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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)
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Current Custody/Visitation Arrangement:_______________________________________________
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Proposed changes in current custody/visitation arrangement: _______________________________
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Does child(ren) have any special needs? _______________________________________________
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Have home studies or psychological evaluations been completed? If so, by whom and dates:
________________________________________________________________________________
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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:
________________________________________________________________________________
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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 ______
M T W TH F SAT SUN From ______ to ______
Do you work any type of alternating or unusual shifts? Explain:
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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:
________________________________________________________________________________
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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?
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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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