Client Intake Form | Let's Straighten It Out

Contact Information

Please provide your contact details so we can follow up after your submission.

First Name *

Last Name *

Email Address *

Phone Number *

Street Address (optional)

City

State

Zip Code

Safety Screening

Georgia law requires mediators to conduct a confidential domestic violence screening before mediation begins. Your answers are kept strictly confidential and help ensure mediation is safe and appropriate for your situation.

Q1. Do you currently have an active protective order against the other party, or does the other party have one against you? *

Yes No

Q2. Is DFCS (Division of Family and Children Services) currently involved with your family? *

Yes No

Q3. Are you afraid of the other party? *

Yes No

Q4. Has the other party threatened you, harassed you, or made you feel unsafe? *

Yes No

Q5. Do you feel safe participating in mediation with the other party? *

Yes No

Q6. Do any of the following apply to your situation? (Select all that apply)

Physical abuse or violence Emotional or psychological abuse Financial control or coercion Stalking or surveillance None of the above

Q7. Do you currently live with the other party? *

Yes No

Important Notice Based on your responses, Shirley will need to speak with you directly before scheduling your mediation session. Please call (placeholder number) to be connected with appropriate support and next steps. Your safety is the priority.

Matter Information

Tell us about the nature of your matter so we can prepare appropriately.

Type of Matter *

County *

Case Number (if applicable)

Other Party's Full Name *

Do you have an attorney? *

Yes No Not sure yet

Case Details

A few more details to help us understand your situation fully.

Which best describes your family situation? *

Are there minor children involved? *

Yes No

How would you describe the asset complexity of your matter? *

Anything else you would like us to know? (optional)

Review and Submit

Please review your information and confirm your consent before submitting.

Let's Get Started

Contact Information

Safety Screening

Matter Information

Case Details

Review and Submit

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