Mountain Mediation Center - Confidential Survey (Domestic) Mountain Mediation Center - Confidential Survey (Domestic) Mountain Mediation Center requires parties in mediation to complete this survey. Your frank, honest answers will enable us to serve your needs better. We recognize these are personal questions, and we will keep all information provided in strict confidence. Please call if you have questions about this survey or if you would rather complete this survey by phone at (435) 336-0060. Name * Who initiated the separation/divorce/custody/paternity action? Who first decided to try mediation? Have either of you become unemployed in the last 60 days? Are you and the other party living together now, or are you separated? Describe how things are going between the two of you now? How do you and the other party usually make decisions about important matters such as finances or your children? If you disagree with each other, how do you handle the disagreement? Are you or the other party a heavy user of alcohol and/or street drugs? Yes No Maybe OtherOther If yes who? Do either of you have chronic mental problems? If yes, are you, the other party, or both currently in treatment? Would you be able to sit in the same room with the other party and a mediator without fear for your safety? Would you be afraid that the other party might hurt you physically if you did not agree with him/her in mediation? In mediation would you fear retaliation from the other party afterwards if you expressed your opinion? If yes, please explain. In mediation would you fear retaliation from the other party afterwards if you disagreed with him/her? If yes, please explain. In mediation would you fear retaliation from the other party afterwards if you asserted your needs? If yes, please explain. Has physical force ever been used in your relationship? If yes, please explain. Has the other party ever threatened you or your family with violence? If yes, please explain. Has the other party ever prevented you from leaving the house, getting a job, returning to school, visiting your family? If yes, please explain. Has the other party ever threatened to kill him/her or had details fantasies about suicide? If yes, please explain. Has the other party ever abused household pets? If yes, please explain. Please select any of the following actions that have happened to you in your relationship: Pushing Strangling / Choking Stabbing Cutting Threatening with a weapon Hitting with an object Hitting with a hand or fist Slapping Shaking Biting Kicking Burning Have forced sexual activities OtherOther Of the options you selected above has it happened more than once and when did this/these action(s) last occur? Have you ever left your home because you feared for your safety? If yes, please explain. Have you or your children ever required medical care because of injuries caused by the other party? If yes, please explain. Have you ever called the police because you feared for your safety from the other party? If yes, please explain. Have the children ever been threatened, hit, hurt, or taken into protective custody? If yes, please explain. Have you ever been cited, arrested, or convicted of hurting the other party or any other person? If yes, please explain. Have either of you ever attended counseling or special classes as a result of physically harming the other? If yes, please explain. Additional concerns or comments: If you are human, leave this field blank. Submit Δ
