Name Your name (First, Middle, Last) Email address (Should be an address that is not accessible to third parties.) Best phone number to reach you Your home address Employer Job title or description Date of marriage City, state, and county of marriage Date of separation Children(For each child, list full name, date of birth, and age.) Have you had, or are you now in counseling? If yes, with whom? Do you have an attorney? If yes, who? Who referred you to mediation? Did any abuse occur during the marriage? (If so, please identify whether physical, emotional, or substance abuse.) Is there a domestic violence protective order or other restraining order? Have you participated in a substance abuse or mental health treatment program? What are your areas of greatest concern about your separation or divorce?