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Mediation Intake Form

  1. For Office Use Only: Para Uso Oficial solamente:
  2. Select One
  3. IN THE CIRCUIT COURT FOR PRINCE GEORGE'S COUNTY, MARYLAND
    Family Support Services, Room M0423, Courthouse, Upper Marlboro, MD 20772
    Tribunal de Segunda Instancia para el Condado de Prince George, Maryland, Servicios de Apoyo Familiar, Sala M0423, Upper Marlboro, MD 20772
  4. MEDIATION INTAKE FORM
  5. Select one (encierre una)
  6. Telephone Numbers/Números telefónicos:
  7. Attorney Provided by Legal Aide Bureau/Community Legal Services/El abogado fue proveído por Legal Aid Bureau/Community Legal Services:
  8. Please answer the following: *All fields required/Por favor responda lo siguiente: *cada una es requerida
  9. Total Gross Yearly Income: Total de su ingreso bruto anual*
  10. Has either party filed for a protective order against the other, either recently or in the past?/Alguna de las dos partes ha solicitado una orden de protección en contra de la otra parte ya sea recientemente o en el pasado?*
  11. There is an active protective order in effect/Existe una orden de protección en vigencia. *
  12. I feel intimidated by or afraid of the other party/Me siento intimidado/a por o con miedo de la otra parte. *
  13. There have been allegations of child abuse or neglect/Han existido alegaciones de abuso o negligencia infantil.*
  14. Child Protective Services has been involved either recently or in the past/La Oficina de Protección a Menores se ha involucrado ya sea recientemente o en el pasado.*
  15. There has been a criminal case between the parties/Ha habido un caso penal entre las partes. *
  16. There are issues of drug use or alcohol abuse for either party/Hay temas de abuso de drogas o alcohol por alguna de las partes.*
  17. There are concerns that might affect either party’s ability to participate in mediation/Hay precupaciones que podrian afectar a alguna de las partes en su abilidad de participar en mediacion.*
  18. Do you need an intepreter/Usted necesita un intérprete?*
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  20. This field is not part of the form submission.