IN THE CIRCUIT COURT OF THE SECOND JUDICIAL CIRCUIT _________________ COUNTY, ILLINOIS IN RE THE MARRIAGE OF: ______________________________, Petitioner v. ______________________________, Respondent. ) ) ) ) ) ) ) ) Cause No.:______________ PRE-MEDIATION QUESTIONNAIRE (To be completed by each party prior to referral for Mediation) Full Name:_________________________________________Dat e of birth:_____________________________ Residence address: ______________________________________________________________________ ______________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Mailing address (if different): Home telephone no.: ________________________Home fax no.(if applicable):___________________________ 1. Are there any past or pending order(s) of protection case(s) involving the parties and/or their children? If yes, where, case number and name of parties/child(ren) involved, and any relevant details._______________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 2. Are there any juvenile court proceedings in which the parties or their child(ren) are involved? If so, where, case number, name of parties/child(ren) involved. ______________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 3. Do you believe there are any impediments/problems that exist in this case that make mediation impracticable or dangerous? If yes, state specific reasons. __________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 4. Do you believe that there are facts that need to be disclosed privately to the mediator before the mediation begins? If yes, state details. __________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Pre-mediation questionnaire 68 Page 1 of 4 1/9/15 American LegalNet, Inc. www.FormsWorkFlow.com Your attorney's name (if applicable): Your attorney's mailing address: Your attorney's e-mail address: Your attorney's office telephone no.: Your attorney's office fax no.: _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ _________________________________________________________ List the names of all Illinois judges who have presided or acted as attorneys in any child custody, visitation, adoption, child guardianship or juvenile court matter in which you have been a party; and, as to each such judge, state the county of the proceedings, the year or years during which the proceedings took place, and, if possible, the name and case number of the case. ______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Are you presently married? ____ Yes ____No If "yes", to whom and since what date? ___________________ __________________________________________________________________________________________ Have you previously been married: ____ Yes ____ No If "yes", to whom and during what period(s): __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please state the names and dates of birth of all of your children, and the name of the other parent of each child. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Please state the names and relationships (to you) of every person residing with you on a full-time basis. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ If any of the persons residing with you full-time are children who are the subjects of the pending court action, name those children and indicate how long they have lived with you on a full-time basis. __________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ _____________________________________________