Screening Form | Pinnacle Mediation

Pinnacle Mediation Intake Form

This form is strictly confidential and is provided to you as part of a Confidential (Closed) Mediation Process.

Disclosure of the information you provide on this form will be permitted only where a child is at risk of harm, any person is in imminent or potential danger, or a judge orders disclosure. Otherwise, Pinnacle Mediation will not share any of this information without your consent, either verbal or written.

This information may be used for research or training purposes with all identifying information removed.

*Please note: it will take you approximately 15 minutes to fill out this form.

IMPORTANT: Each party is required to fill out and submit their own form.

[DISCLAIMER: DESPITE OUR BEST EFFORTS, WE CANNOT GUARANTEE THAT ALL INFORMATION SUBMITTED ELECTRONICALLY IS 100% SECURE AND PRIVATE]

If you have any of the following documents please provide PDF or JPEG copies:

Relevant Court Orders, Briefs, and Memorandum
Relevant Endorsements and Temporary Judgments
Financial Documentation
Bail conditions / No Contact Order / Probation Order / Peace Bond / Parole Order / Notice of Recognizance
OCL Report / Voice of the Child Report / Parenting Assessment (private) / Children’s Aid Report or letter / Children’s Aid Society Worker’s name, address and telephone number.

Section 1: Court Info

Have you or the other party filed or been served with a Form 8A / Form 8 (Application), a Motion to Change (Form 15), or a court order at a Toronto Family court?

Yes

Do you have a temporary court order?

Yes

Section 2: Basic Information

First Name

Last Name

Age

Other Languages Spoken

Phone

Can we contact you at the phone number you provided

Yes

Can we contact you at the email address you provided

Yes

Can we share your email with the other party?

Yes

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Your Lawyer's First Name

Your Lawyer's Email

Your Lawyer's Last Name

Your Lawyer's Phone Number

Other Party's First Name

Other Party's Last Name

Other Party's Age

Do you wish to self-identify as an Indigenous person in Canada, such as First Nation, Métis or Inuit?

Yes

Do you have any disabilities you would like us to know about?

Yes

Section 3: Relationship History

Are you currently seperated from the other party?

Yes

Are you comfortable to meet in the same room with the other person?

Yes

Are you able to talk about the things that are important to you with the other person?

Yes

Do you have any concerns for the safety of the children?

Yes

We don't have any children

Do you have any concerns about the other person's alcohol or drug use?

Yes

Do you have any concerns about the other person's mental health?

Yes

Do you have any concerns for your safety?

Yes

Do you have any other concerns that you want to discuss with the mediator?

Yes

Section 4: Employment & Income

Employmen Status

Employed

Self-Employed

Unemployed

What is Your Approximate Gross Annual Income?

Job Position

Do you receive income from any of the following sources?

If you selected other above, please indicate the other source(s) of income

What is the Other Party's Approximate Gross Annual Income?

Other Party's Job Position

Section 5: Abuse & Misconduct

Did you experience any abuse in the relationship?

Yes

Was there any child abuse in the relationship?

Yes

Has the other party been cited for any professional misconduct?

Yes

Have you ever been arrested?

Yes

Has a warrant of committal been issued agaisnt you?

Yes

Has the other party ever been arrested?

Yes

Has a warrant of committal been issued agaisnt the other party?

Yes

Section 6: Children's Information

Are there any childen of the marriage?

Yes

How many children of the marriage?

Child's Full Name

Child's Date of Birth

Child is currently living with

Child # 2 Full Name

Child #2 Date of Birth

Child #2 is currently living with

Are there any childen from a previous relationship?

Yes

How many children of the previous relationship?

(Previous Relationship) Child's Full Name

(Previous Relationship) Child's Date of Birth

(Previous Relationship) Child is currently living with

(Previous Relationship) Child # 2 Full Name

(Previous Relationship) Child #2 Date of Birth

(Previous Relationship) Child #2 is currently living with

Are there any childen from a current or new relationship?

Yes

How many children of the current or new relationship?

(Current/New Relationship) Child's Full Name

(Current/New Relationship) Child's Date of Birth

(Current/New Relationship) Child is currently living with

(Current/New Relationship) Child # 2 Full Name

(Current/New Relationship) Child #2 Date of Birth

(Current/New Relationship) Child #2 is currently living with

Are you currently paying child support for child(ren) from a previous relationship

Yes

Are you currently paying spousal support to a spouse from a previous relationship

Yes

Is the other party currently paying child support for child(ren) from a previous relationship

Yes

Is the other party currently paying spousal support to a spouse from a previous relationship

Yes

Section 7: Documentation

Has a Children’s Aid society been involved with your family?

Yes

Has the Office of the Children's Lawyer been involved with your family?

Yes

Is there a protection or No Contact Order in place? (Or probation order, bail conditions, peace bond, restraining order)?

Yes

Do you have a separation agreement?

Yes

Have you filled out a Form 13 or Form 13.1 (Financial Statement) within the last 12 months?

Yes

Section 8: Issues For Mediation

Section 9: Privacy & Technology

Are you living in the same residence as the other person?

Yes

Do you have a private place where you can have an online meeting without anyone else hearing or watching you (including children)?

Yes

Do you have your own computer that is private, password-protected, has a camera and a microphone?

Yes

Consent to the Privacy Policy: I have read and agree to the Privacy Policy.

Yes

Consent to the Privacy Policy

I have read and agree to the Privacy Policy.View Privacy Policy

Consent to the Terms and Conditions of Mediating with Pinnacle Mediation

I have read and agree to the Terms and Conditions of Mediating with Pinnacle MediationView Terms and Condtions

Section 10: Submitting Documents

If you have any of the following please attach them below:

Relevant Court Orders, Briefs, and Memorandum
Any Relevant Prior Agreements
Relevant Endorsements and Temporary Judgments
Financial Documentation
Bail conditions / No Contact Order / Probation Order / Peace Bond / Parole Order / Notice of Recognizance
OCL Report / Voice of the Child Report / Parenting Assessment (private) / Children’s Aid Report or letter / Children’s Aid Society Worker’s name, address and telephone number.

Upload File

Please attach a copy* of your valid driver's license or passport below (*screenshot or png).

Upload File

Thanks for submitting!