New Mexico > Local District Court > 11th Judicial District > San Juan County > Mediation
Questionnaire (For Mediator From Parties) - New Mexico
| Questionnaire (For Mediator From Parties) Form. This is a New Mexico form and can be used in Mediation San Juan County 11th Judicial District Local District Court . |
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Q U E S T I O N N A I R ENAME: ________________________________________DATE: _________________Address: ______________________________________ Home Phone: ____________City: ____________________________ Zip: __________Work Phone: ____________ATTORNEY: ___________________________________ Phone: ________________Address: ________________________________________ City: _____________________________Zip: ___________ INSTRUCTIONS: This is a quicker way to know you better. The questions have manypossible answers and there are no right or wrong responses. Please respond briefly andhonestly. THE CHILDREN: Please consider each child separately in responding to thesequestions. Only the children involved in the custody or time-sharing dispute need to beconsidered in these responses. Child(ren) involved: Name ____________________________________ Age _____________Name ____________________________________ Age _____________Name ____________________________________ Age _____________Name ____________________________________ Age _____________1. Describe each of your childrens personalities. What do you like and dislike about them? What do you see as their strengths and weaknesses?2. How, and for what, do you discipline your children?3. How do you think your children will be, or have been, affected by the divorce? 1<<<<<<<<<********>>>>>>>>>>>>> 24. How do you rate yourself as a parent? What are your strengths and weaknesses?5. How do you rate your (former) spouse as a parent? What are his/her strengths and weaknesses? 6. Do your children know their custody is being disputed or that there is a time-sharing problem? What have you told them about it? 7. What custody/time-sharing arrangements do you think would be most beneficial to each child? Why? 8. What reasons do you expect your (former) spouse will give as to why you should not be given custody of the children or should not have more time with them?YOUR HISTORY: 9. How is your health, both mental and physical? Do you have any problems that have required long or continuous health care? 10. Are you employed? If so, what is your job and how do you like it? What do you like most and least about your work? 11. Since your separation or divorce, who have the children lived with? Please give dates. 2<<<<<<<<<********>>>>>>>>>>>>> 312. Do you or does your (former) spouse have other children? If so, please give their names, ages, and where they live. 13. Do any of the children have emotional or physical problems? What doctors or therapists have cared for them? 14. Residence History: Please list the residences at which you have lived since the birth of the oldest child involved in this dispute. Start with your present address and work backwards. Please give the dates for each address. 15. Employment History: Please list your employment history for the last ten years. Start with your present job and work backwards. Job Employer Dates Reason for Leaving16. Marital History: Please list the times you have been married. Begin with the present and work backwards. Spouses Name Dates Number of Children17. Do you, or does your (former) spouse, have any emotional or physical health problems? If so, please state the problem and if, how, and when it was resolved. 18. Have you, or has your (former) spouse, ever had a drinking or drug abuse problem? If so, please describe the problem and if, how, and when it was resolved. 19. Do you, or does your (former) spouse, have a criminal record or any criminal actions pending? If so, please state the offenses and sentences given. 20. Are there allegations of abuse? If yes, please explain. Is there an investigation 3 <<<<<<<<<********>>>>>>>>>>>>> 4 pending or completed? 21. The New Mexico Statue defines joint legal custody as being a continuation of the current situation. That is neither parent will make a major change affecting the child(ren) without consulting the other parent in the areas of religion, residence, non- emergency medical or dental care, education, or major recreational activities. Before such a change is made, the parents will discuss the matter, and both parents must agree. 22. The Status Quo - What you now have: CHILD #1 CHILD #2 CHILD #3 CHILD #4 Name: Date of Birth: Age: Residence: (City & State Only) Religion: Doctor: (Name & Phone No.) Dentist: (Name & Phone No.) Child Care Provider (Names & Phone No.) School: (Name & Grade) Major Recreational Activities: Other: 4 <<<<<<<<<********>>>>>>>>>>>>> 523. With regard to each child just listed, please indicate the following, specify the childs name: Special Needs of each child such as learning disabilities, medical problems (like diabetes, epilepsy, heart problems, etc.), physical disabilities; etc. Child 1 - Child 2 - Child 3 - Child 4 - Has the child ever received any type of counseling? If yes, when and with whom? Child 1 - Child 2 - Child 3 - Child 4 - Has the child ever been abused by either parent? Child 1 - Child 2 - Child 3 - Child 4 - 5
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