Divorce Mediation Intake Questionnaire — Form Fields
This legal template includes 17 fields. Intake questionnaire for individuals entering divorce mediation proceedings. Free to customize and use on ZenBuild.
Full Name (text, required)
Date of Birth (text, required)
Email (email, required)
Phone Number (text, required)
Spouse's Name (text, required)
Marriage Date (text, required)
Date of Separation (text, required)
Number of Minor Children (number, required)
Children's Names and Ages (text, optional)
Custody Arrangement Sought (dropdown selection, required) — options: Joint Legal and Physical, Joint Legal - Primary Physical to Me, Joint Legal - Primary Physical to Spouse, Sole Custody, To Be Determined
Own Real Property Together (multiple choice, required) — options: Yes, No
Own Businesses Together (multiple choice, required) — options: Yes, No
Combined Estimated Assets (dropdown selection, optional) — options: Under $100K, $100K-$500K, $500K-$1M, $1M-$5M, Over $5M
Issues to Mediate (checkboxes, required) — options: Child Custody, Child Support, Property Division, Spousal Support, Debt Division, Retirement Accounts, Business Interests, Pet Custody
Domestic Violence History (multiple choice, required) — options: Yes, No
Attorney Retained (multiple choice, required) — options: Yes - Have Attorney, No - Considering, No - Self-Represented
