Step 1 of 4 - Online Intake Form 25% Your Name* Your First Name Your Last Name Best phone number to reach you*What is your email address? What is your mailing address?* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code What is the other person's name?*What is their phone number, if known?What is their email address, if known? What is their mailing address, if known?If there are children, list their first names and DOB.If there are children, are or were you and the other parent married?YesNoDo you have an attorney?*Yes, At no chargeYes, Limited scopeYes, Full pay (substitute: retained)No, I'm representing myselfIf yes, who is your attorney?Does the other party have an attorney?YesNoNot ApplicableDo you need information about how to get legal representation or limited scope legal advice?CMC does not provide legal representation but may be able to help with legal referrals.YesNoWhat kind of mediation service do you need?*Divorce with minor childrenDivorce with no minor childrenPost-divorce Modification of Parenting PlanPost-divorce Modification of MDANever-married Parenting PlanPlease indicate what property you own.Check as many as apply. House/Land Retirement Accounts or Pension Business Not Applicable Other What are the main issues you need to discuss in mediation? Please choose the option that best describes your relationship with the other party:*Very FriendlyCooperativeDifficult but workableHigh conflictVirtually no contactI feel comfortable/secure being in the same room as the other party.*Strongly agreeAgreeDon't knowDisagreeStrongly disagreeThe other party has an even/calm disposition.*Strongly agreeAgreeDon't knowDisagreeStrongly disagreeIf the other party and I disagree, we resolve our differences by talking it out.*Strongly agreeAgreeDon't knowDisagreeStrongly disagreeIs there a current Order of Protection or restraining order?*YesNoNot now, but within the last 2 years.If yes, in what court is the matter and what docket number, if you know?Have the police or sheriff's offices been called?*YesNoNot now, but within the last 2 years.If there is a history of abuse, either physical, emotional or both, please briefly describe the behavior.* Have you or the other person filed a case in this matter?*YesNoIf yes, in which court is your case filed?*Knox County 4th Circuit CourtKnox County Chancery CourtKnox County Juvenile CourtDo you have a court order for mediation (Rule 31)?*YesNoMy existing Parenting Plan says I need to use a Rule 31 mediator.Have you taken any required Parenting Classes?*YesNoI need information about reduced fee Parenting Class options. Are you employed?*Yes, full timeYes, part-timeNoSelf-employedWho is your employer?What is your household income before taxes?*You will need to show financial documentation to qualify for a reduced fee. Household income includes your income and that of any other person you live with who contributes financially to your living expenses.$0 - $23,000$23,001 - $31,000$31,001 - $39,000$39,001 - $47,000$47,001 - $55,000$55,001 - $63,000$63,001 - $71,000$71,001 - $79,000$79,001 and upHow many individuals, including yourself, does your household income support?*Is the other party employed?*Yes, full timeYes, part-timeNoSelf-employedDon't knowAgreement* I agree to the terms of service EmailThis field is for validation purposes and should be left unchanged.
