Genesis Christian Mediation: Therapeutic SeparationThank you for taking the steps to mend and heal your relationships. Name * First Name Last Name Email * Phone (###) ### #### Address Address 1 Address 2 City State/Province Zip/Postal Code Country Mailing address (if different from above) FAMILY AND MARRIAGE INFORMATION I'm Ready! Children From This Marriage: Name and Age Date of Marriage * MM DD YYYY Did you cohabit before marriage? * Yes No If you cohabitated before marriage, how many years? Are you currently separated? * Yes No If separated, what was the date of separation? * Is this your First Marriage? * Yes No Which Marriage is this? * First Second Third Fourth Are there children from the first marriage and are they still in the home? * Ages of children from a previous marriage if they are still in the home * How did you contribute to this conflict or difficulty you are experiencing in your family? * Date when last marriage end? MM DD YYYY MEDIATION FIRST STEPS * You will need to enter "none" or "n/a," if you have no response for a section. I'm Ready! In as much of a summary as you can, "how did we get here?" * Do you have any concerns or fears going into this process? * What are some of your questions about the mediation process? * List one or two goals (or hopes) for this process? * Do you have other information or thoughts which you did not share in the consult which you would like us to know or be aware of? * Are there any mental health or trauma/abuse concerns we should be aware of? * Please watch this YouTube video. Keep in mind there is no sound and there is a lot of information presented. You will be asked to respond to the content. View the video here. Done! What in the video caught your attention? * What is the most difficult area of listening for you? * THE FOUR HORSEMEN I'm Ready! Watch this video and answer the following questions. Which of the four areas do you struggle with the most? * View the video here. How have you seen one of these impact your relationship? * When watching this video, did it bring up any specific moment or situation for you? What was it? * THE CONVERSATION PATHWAY I'm Ready View the following slide. Where do you feel your communication has broken down in looking at this pathway? View the image here. If you were to name one of the four areas named above -- listening, clarifying, validating, responding -- in which you need or your spouse needs most improvement, what might it be? * In what area on this pathway, where has communication difficulty occurred? Which has had the largest negative impact on your relationship? * THERAPY AND SUPPORT HISTORY I'm Ready I am currently seeing a counselor or therapist * Yes No Name of Individual Therapist I have previously seen an individual counselor/therapist * Yes No We are currently seeing a marriage counselor/therapist? * Yes No We have previously seen a marriage counselor/therapist * Yes No Name of marriage counselor/therapist How did you hear about Genesis Christian Mediation? * Personal Referral Internet Search Counselor Church/Pastor Other Organization Other Source Please share the name of the counselor, church/pastor, personal referral, or other referral source. Thank you!
