Client Intake Questionnaire

Tell Us About Your Situation

This questionnaire helps us understand your situation so we can recommend the best path for you—DIY divorce support, mediation, conflict coaching, or a combination. Please answer as honestly and clearly as you can. There are no perfect answers.

Important: Mediation & Mitigation Solutions is not a law firm and does not provide legal advice, representation, or mental health treatment. Completing this form does not create an attorney–client relationship. This is an informational intake to help us see if our services are a good fit and to help you get organized.

1. About You

Basic contact information so we know who you are and how to reach you.

Full Name

First and last name as you’d like us to use when we contact you.

Best Email Mobile Phone Preferred Contact Method

Email, text, phone call, or other.

City & State

So we understand your general location and time zone.

How did you find Mediation & Mitigation Solutions?

Google, YouTube, referral, social media, workshop, or other.

2. Who Else Is Involved?

Tell us who the other person or people are in this situation. This might be a spouse or ex, co-parent, family member, or someone else you’re in conflict with.

Name of Other Party (if applicable)

You can use initials if you’re not comfortable sharing full names yet.

Your Relationship to Them

Examples: spouse, ex-partner, co-parent, sibling, parent, co-worker, other.

Are there children involved?

If yes, please list their ages and whether they live primarily with you, the other party, or both.

3. What Brings You Here?

A brief snapshot of what’s going on and what you’re hoping to change. This doesn’t have to be perfect—just your honest perspective in your own words.

In your own words, what is happening right now?

A short description of the main issues or patterns that concern you.

How long has this been going on? What have you already tried?

Examples: individual therapy, couples counseling, prior mediation, attorneys, doing nothing, etc.

What worries you the most about the current situation?

4. Legal & Process Status (If Applicable)

This section helps us understand where you are in any formal process. If you’re not sure or nothing has been filed yet, that’s completely okay—just answer as best you can.

Has anything been filed with the court related to this situation?

Yes / No / Not sure. If yes, briefly describe (for example, “divorce filed,” “custody motion,” “restraining order,” etc.).

Are any attorneys currently involved?

If yes, please indicate whether you have an attorney, the other party does, both do, or neither does.

Are there any upcoming court dates, deadlines, or major events?

If yes, please list approximate dates and what they’re for.

5. Safety & Emotional Climate

Your safety and emotional well-being matter. The more honest you are here, the better we can understand how to proceed and whether mediation or coaching is appropriate.

On a scale of 1–5, how emotionally safe do you feel around the other party?

1 = not safe at all, 5 = very safe.

Have there been any concerns about emotional, verbal, financial, or physical abuse?

You may share as much or as little as you’re comfortable with here.

Do you have any current safety concerns for yourself or your children? Is there anything you want us to know about mental health diagnoses, addiction, or extreme behavior patterns?

Only share what you feel comfortable sharing. This can help us understand whether specialized support is needed.

6. Financial Snapshot

You don’t need exact numbers here—just a general picture so we understand the level of financial complexity and stress.

Are you currently able to meet your basic monthly expenses?

Yes / No / Barely / It depends.

Very roughly, how would you describe your financial situation?

For example: “basic paycheck to paycheck,” “high debt load,” “mix of wages and business income,” “own a home with equity,” etc.

Are there shared assets or debts that need to be discussed?

Examples: house, retirement accounts, loans, credit cards, business, etc.

7. What You’re Looking For

This section helps us match you with the right services and set realistic expectations for our work together.

Which services are you most interested in?

DIY divorce coaching, full mediation, conflict coaching, narcissistic abuse recovery, parenting support, or “I’m not sure yet.”

What would a “good outcome” look like for you 6–12 months from now? What do you feel you need most right now?

Examples: clarity, a plan, emotional support, better communication tools, help preparing for mediation, etc.

Is there anything else you’d like us to know before we talk?

8. Next Steps

After you submit this questionnaire, we’ll review your responses and follow up with recommended next steps. This might include a consultation, a coaching session, mediation options, or resources that fit your situation.

Please double-check your contact information so we can reach you. If you have an urgent safety concern, contact local emergency services or a trusted crisis resource before waiting for a response from us.