Personal Injury Form
The information provided in this form will allow me to better understand your situation. It will be kept confidential and will not be shared without your consent with anyone (except my assistants).
Section 1: Your Information
Your Name (required)
Name on Birth Certificate
Date of Birth
SIN
Place of Birth
Address
Home Phone Work Phone Cell Phone
How long have you lived in Alberta?
Who lives with you?
Do you work? Full TimePart TimeNo If No, why not?
Your Occupation?
Job Title
Gross Monthly Salary
Total Income of your last ITR
Name of your employer
Section 2: Spouse Information
Where does he/she live?
Does he/she work? Full TimePart TimeNo If No, why not?
His/Her Occupation?
Total Income of his/her last ITR
Name of his/her employer
How long has your spouse been living in Alberta?
Section 3: Relationship
When and where did you start living together?
When did you get married?
Do you have a copy of your marriage certificate? YesNo
Do you have a pre-nuptial/marriage contract? YesNo
When and where did you separate?
Do you have a separation agreement? YesNo
Is reconciliation possible? YesNo
At the time of the marriage were you single? YesNoDivorced If so, when and where?
Section 4: Children
Do you have children with your current spouse? YesNo
If yes, please provide their full names and date of birth
If you are separated, with whom have the children been living with?
Did you bring any children to your current relationship? YesNo If yes, please provide their full names and date of birth
Did your spouse bring any children to your current relationship? YesNo If yes, please provide their full names and date of birth
Section 5: Property
During your marriage did you receive any: Assets owned prior to marriageInheritancePersonal Injury Settlement
During your marriage did your spouse receive any: Gifts from a 3rd partyInheritancePersonal Injury Settlement
You: Matrimonial home:Other real estate:Contents:Art:Jewelry:Collections:Vehicles:Trailer/Motor Home:Boat:Misc. Equipment/Machinery:Livestock:Tools:Bank Accounts:Term Deposits:Aeroplan/Aeromiles:Life Insurance:Stocks/Bonds:Stock Options:Pensions:RRSPs:CPP:Corporate Interests:Business/Partnerships/Joint Venture:Mortgages/Agreement for Sale:Trusts:Other Assets:Assets held in:Trust for Children: Your Spouse: Matrimonial home:Other real estate:Contents:Art:Jewelry:Collections:Vehicles:Trailer/Motor Home:Boat:Misc. Equipment/Machinery:Livestock:Tools:Bank Accounts:Term Deposits:Aeroplan/Aeromiles:Life Insurance:Stocks/Bonds:Stock Options:Pensions:RRSPs:CPP:Corporate Interests:Business/Partnerships/Joint Venture:Mortgages/Agreement for Sale:Trusts:Other Assets:Assets held in:Trust for Children:
Debts
You: Credit Cards:Line of Credit:Bank Loan:Loan from 3rd Party:Personal Guarantee:Income Taxes:Other: Your Spouse: Credit Cards:Line of Credit:Bank Loan:Loan from 3rd Party:Personal Guarantee:Income Taxes:Other:
Miscellaneous Property Issues You: Gifts from assets since separation?:Sale of assets since separation?:Debts since separation?: Your Spouse: Gifts from assets since separation?:Sale of assets since separation?:Debts since separation?:
Section 6: Other Information
What have you done to deal with your conflict so far? CounselingMediationWritten AgreementsCollaborative ProcessCourt Proceedings Have you consulted a lawyer? YesNo Does your spouse have a lawyer? YesNo If yes, what is that lawyers name?
On a scale of 1-10, with 1 being low and 10 being high, rate your conflict: Has there been any violence in your relationship? If so, explain? Has the Police been involved Have criminal charges been laid? Are they resolved? Are there any court orders? If so list the 3 most recent by date: What issues have you resolved? What are your 3 most urgent issues? Do you have any future court dates? Which process do you prefer to use? (Please refer to my website for more info): NegotiationMediationLimited scope representation(unbundling)Litigation
How did you hear about Dr. Dorczak?
Family Dispute Questionnaire
Elder Mediation Questionnaire Form
Other Inquiries Form