New Meditation Clients

NEW MEDIATION CLIENT INFORMATION FORM

INSTRUCTIONS: Please fill this out prior to your initial appointment with Dr. Winder. Each party should fill this out by themselves. This form is ONLY for Dr. Winder to read so he can understand where each of you believes you are in the process. All information is optional. The more information you include here, the more productive your first mediation session will be.


Education:


Marriage:


Children

Children from present marriage and other children living in household:


SEPARATION/DIVORCE

Indicate below the names and approximate date of last contact you had with:


EMPLOYMENT INFORMATION


FAMILY FINANCES


HEALTH INSURANCE


PRIOR MARRIAGES

PRESENT SITUATION


ANYTHING ELSE?

Please Enter Your Name And Phone Number And We Will Reach Out Shortly

Start today with Dr. Winder's unique STEP program and begin the journey towards more happiness and less pain.