Mediation of Parenting Plan

SERVING WAUKEGAN, LIBERTYVILLE, LAKE COUNTY, GURNEE & NEARBY AREAS OF ILLINOIS

Law Offices of
Thaddeus M. Bond, Jr. & Associates, P.C. _
708 Florsheim Drive - Suite 10
Libertyville,IL 60048
Phone: 847.599.9101
Fax: 847.599.9914
Email: [email protected]

INTAKE QUESTIONNAIRE FOR
MEDIATION OF FINANCIAL ISSUES

Please submit this intake sheet along with copies of both parties W-2s and income tax returns from last year, most recent three paystubs for this year, two most recent retirement account statements, two most recent account statements for any CDs, IRAs, bank accounts, credit card statements, life insurance, annuity, stock option documentation, stock account statements to our office prior to the mediation session.
Date:
MM slash DD slash YYYY
WIFE/MOTHER PERSONAL INFORMATION
Name:*
Date of Birth:*
MM slash DD slash YYYY
Address:*
Cell Phone:*
Home Phone:
Email Address
SSN:*
Maiden Name:
Birthplace:
Occupation:
Employer's Name:
Employer's Address:
Employer's Phone No:
Orders of Protection
Parties:
Dates:
MM slash DD slash YYYY
Is Order in effect:
HUSBAND/FATHER PERSONAL INFORMATION
Name:*
Date of Birth:*
MM slash DD slash YYYY
Address:*
Cell Phone:*
Home Phone:
Email Address
SSN:*
Occupation:
Employer's Name:
Employer's Address:
Employer's Phone No:
Orders of Protection
Parties:
Dates:
MM slash DD slash YYYY
Is Order in effect:
MARRIAGE (IF APPLICABLE)
State, City and County of marriage:
Living with Spouse Now:
If not, date separated:
NOT MARRIED (IF APPLICABLE)
Approximate date the parties began relationship:
Approximate dates between which parties’ resided together:
Approximate date of parties’ separation:
CHILDREN - MUST HAVE ALL INFORMATION REQUESTED
Names:
Date of Birth:
MM slash DD slash YYYY
Present Residence:
Parenting Plan:
1. Allocation of Parenting time:
2. Allocation of Parenting Responsibilities:
Sole Responsibility For One:
Any adopted children? (Names, Dates of birth):
Wife/Mother presently pregnant?
3. Parenting Time: Please describe the routine or weekly parenting time schedule you envision for your family:
Do the children own property other than personal effects? If yes, identify:
Prior to separation (for parents presently residing together):
After separation (for parents residing separately):
4. Transportation: Please describe the type of transportation arrangements you would like to effectuate the parenting time:
5.Type of contact when children are not with parent: Please describe the type of contact you would like each parent to have with the children when the children are with the other parent.
Daily telephone contact (set times/days)
Contact via e-mail/text/Skype/Tango
Other:
6. Holiday Parenting Time: Please describe the type of holiday parenting time you envision for your family: (alternating holidays, time frame for holidays, specific holidays based upon family traditions)
7. Vacation Parenting Time: Please describe the type of vacation parenting time you envision for your family:*
9. Do you desire a right of first refusal to provide care for the minor child(ren) during the other parent’s parenting time in the event the parent will be away from the children for a period of time?
If yes, what period of time would a parent be absent during his/her parenting time in order for this provision to be effective?
10. Any additional issues, which require discussion in terms of any restrictions/supervision of parenting time, please list issue and describe history.
Date:*
MM slash DD slash YYYY
Email Address:*
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Mediation of Parenting Plan

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