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Child Custody Mediation Parent Intake Form

The purpose of mediation is to develop a plan that ensures that children have a good relationship and lots of time with each parent.

Introduction To Mediation

Lake County Family Court Services.

This CONFIDENTIAL information is for the mediation office only and will not be given to the other parent.

Mediation Guidelines:

  • Treat all people and topics with respect.
  • Each person has a right to speak and be heard.
  • Be as honest as you can.


  1. The mediator asks each person to talk about the situation and speak directly to the mediator at first.
  2. The mediator invites the parents to talk directly with each other.
  3. Parents are asked to listen carefully and be able to say back what they heard the other person say.
  4. Parents offer ideas to build a plan that will work for the children and for each parent.
  5. Parents choose the ideas they agree about.

Confidentiality - Everything discussed in mediation is confidential. This means:

  • No information from mediation is given to the court.
  • No recording of any kind is allowed.
  • No other person may be present or able to overhear the conversation.
  • No communication with the other party or anyone else while we are having the conversation.


  • The Mediator is required to report child abuse or threats of violence. 

Mediation Parent Intake form

Mediation Intake Webform

Personal Information

I am a

Work Information

Family Information

Names of other Adults in your Home Relationship to you
Name of the Attorney Phone number
Other Parent's Name

Other Information

First and Last Name Age Date of Birth Sex School Time with each Parent
Name Age
Do you plan to move in the next six months?
Do you have another case in Family Court Services?
Have you ever feared you would not be able to see your children?
Do you have any concerns regarding the use of alcohol and/or drugs by family members?
Have there ever been any physical confrontations between you and the other parent?
Were the children present or able to see or to hear it?
Have there ever been threats of the use of weapons against either of you parents or your children?
Have you ever asked for a restraining order against the other parent?
Has the other parent ever been abusive to any other family member?
Has the other parent ever been abusive to a family pet or other animal?
Has there ever been a criminal domestic violence case against the other parent?
Do you have any concerns about your own physical safety?
Do you believe that you are considered an equal partner with the other parent?
Has any adult ever used physical punishment on your child?
Has Child Welfare Services investigated abuse of any of your children?
Have you ever been arrested as an adult?
What State County What Charges?
Are there any criminal actions pending against you or any adult in frequent contact with the child(ren)?
Name of the Adult What State County What Charges?
Do you have a current PROTECTIVE ORDER of any kind?
RIGHT TO SEPARATE SESSIONS: If a party alleges domestic violence in a written declaration under penalty of perjury, or a party protected by a protective order so requests, Family Court Services staff must meet with the parties separately at separate times. DO YOU WISH TO BE SEEN SEPARATELY?
RIGHT TO A SUPPORT PERSON: If the court has issued a PROTECTIVE ORDER, a support person shall be permitted to accompany protected party during any mediation orientation or mediation session, including separate mediation sessions. It is the function of a support person to provide moral and emotional support. The support person is not present as a legal adviser and shall not give legal advice. DO YOU WISH TO HAVE A SUPPORT PERSON ACCOMPANY YOU IN MEDIATION?


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