Salem Alliance Church

Personal Information                                                                                              Date 

Name                                   Age   
Address                                 Zip    
Email                       
Telephone: Daytime          Evening   
Employer                    Occupation 
Referred by             
Marital Status (mark all that apply)
Never married  Widowed  Divorced Married Yrs   Separated months   
Spouse’s name         Age  
Names and ages of your children:

Describe any significant health issues that might impair your ability to effectively participate in mediation:

Do you have an attorney? select oneYesNo  Attorney's Name:
Attorney's Address:
Has a legal action been filed or is one likely to be filed in this situation? select oneYesNo (describe below)


Have you received advice from anyone else regarding this situation? select oneYesNo(describe below) 


Religious Background
Religion:  NoneChristianJewishAgnosticOther  Do you believe in God? YesNoUncertain 
How often do you pray to God? DailyWeeklyIrregularlySeldomNever  What church do you attend? 
Pastor     Address   Phone   
Member? YesNo  How often do you attend church?  weekly  Irregularly  Seldom    Never
Church leadership positions you hold or activities you are involved in:

How often do you read or study the Bible? DailyWeeklyIrregularlySeldomNever
What is your view of the authority of Scripture?

Who has the most influence on your religious or spiritual life? Please give names and relationship.



Other Person in conflict
If there is more than one other person, please mark the box below and provide the same information about them on additional sheets.
Name                  
Relationship        How long   
Mailing address   Zip 
Email                 
Telephone: Daytime Evening Fax
Church            Attorney  
Employer   Occupation 
This person’s religious orientation and commitment



Information on Your Problem or Dispute
Briefly describe your problem or dispute (you can give us more detailed information later during an interview):

What have you done to resolve this problem or dispute?

What issues or questions do you want to have resolved or answered?

What do you want us to do?

If this is a legal matter, what are you asking for? (Include dollar amount, if any)

Other information we should know?