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Hear the Child Report Intake Form

The information that you provide to us in this document is intended to be kept confidential between you and Riverdale Mediation Ltd. as it is provided as part of a confidential dispute resolution process. No party may seek disclosure of what the other wrote on their intake forms and we will keep your information confidential.

There are however exceptions to confidentiality in family dispute resolution including our duty to report to a Children’s Aid Society if a child is at risk of harm; our duty to warn a person if there is a threat to their safety; or if a judge orders us to disclose information to the court.

By completing this intake form you agree to these terms. Please ask us if you have any questions.

NOTE: Each party is required to complete and submit their own form.

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Hear the Child Report Intake Form

It is important that you complete the following form accurately as possible.

Date*
MM slash DD slash YYYY
Name*
First Last
Phone (Primary)*
Email*
Your lawyer:
Other party lawyer:
Other counsel involved:
Is the report for (please check one):*
- Mediation
- Arbitration
- Parenting Coordination
- Court
- Other
If "Other" was selected above, please specify:
To whom is report to be distributed?*
When is report required?
MM slash DD slash YYYY
Please provide details (eg/court file name and number; name of arbitrator, mediator or parenting coordinator):*
If there is an Order or Agreement for a HTC Report please upload it here:
Drop files here or
Max. file size: 30 MB.
Is there a reason why interviews cannot be in person?*
Date of separation?*
Upload copy of any current Court Order or Agreement regarding parenting arrangements:
Drop files here or
Max. file size: 30 MB.
Describe current issue(s) in dispute that have led to the request for a HTC Report?*
Description of Current Parenting Time Schedule:*
Issues to be canvassed with the child(ren):*
Contact Information for Guardians/Lawyers:
Parent 1:*
Name: Phone: Email: Lawyer: Lawyer's Phone: Lawyer's Email
Parent 2:*
Name: Phone: Email: Lawyer: Lawyer's Phone: Lawyer's Email
Other Guardian:
Name: Phone: Email: Relationship to Children: Lawyer's Email: Lawyer's Phone: Lawyer's Email
Children
Other Guardian:*
Name of Child: To be interviewed? (YES/NO) Gender: Age/DOB Any special needs? Grade:
Consent to Cloud Storage*
We acknowledge that Riverdale Mediation Ltd. uses a Google Drive for the storage of information relating to your case.
I consent to the use of “the cloud” for file storage purposes.
Consent to use of DropBox for file sharing*
I consent to the use of “DropBox” for file sharing purposes.
I acknowledge that Riverdale Mediation uses a DropBox for sharing files among clients, counsel and the FDR professional.
Consent to the Privacy Policy*
The Privacy Policy can be viewed here.
I have read and agree to the Privacy Policy.
Consent to the Terms of Online Dispute Resolution*
The Terms of Online Dispute Resolution can be viewed here.
I have read and agree with the Terms of Online Dispute Resolution.
Date*
Signature*
First Last
Hidden
Administrative
Hidden
Intake Form
Hidden
Sharepoint ID
Hidden
Name (Unencrypted)
First Last
Hidden
Email (Unencrypted)
Name
This field is for validation purposes and should be left unchanged.

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