Intake Questionnaire

How did you hear about Separation pathways? *

My Ex found you
Google Search
Facebook
TV advertising
LinkedIn
TV or Radio interview
Webinar or live event
Word of Mouth
Professional Referral
Toronto Transit ( Subway)
Other

Please specify

Please specify program

The questions on this form are intended to support us in assisting you. Those with a (*) are required. Only answer others that you are comfortable answering.

This system is confidential. By proceeding, you agree for us to share your information within our internal team only and never shared with third parties. Your information will be stored securely in Canada, and you can pause and come back later if you like. For Terms of Service please visit our Privacy page.

Name *

First

Last

Preferred Name (if different)

What are your pronouns (He/She/They)?

Email *

Is it safe to send you email? *

First three digits of your postal code *

Best telephone number to call: *

Alternate telephone number to call:

Best time of day to call: *

Is it safe to leave a voicemail? *

The other party's name (your ex/spouse/partner/co-parent): *

First

Last

This information is to ensure we connect both parties' files.

Layout program your

Have you separated? *

The separation was initiated by:

Me
My partner
Both of us

Date of marriage or cohabitation *

Are you and your partner still living in the same home? *

Are you in a new relationship?

Does your spouse/partner have a new relationship?

How many children do you have together? *

No Children
1 Child
2 Children
3 Children
4 Children
More than 4 Children

Ages of the children:

0-1
2-4
5-9
10-14
15-18
19-24
25+

Please check all that apply

-----

What are you most concerned about? Check all that apply:

Safety Concerns (for yourself, children, pets, or others)
Co-Parenting (parenting time and decision making)
Child Support
Special Needs (child/ren)
Asset Division (home, investments, pension, etc)
Spousal Support
Income Concerns
Physical Health Concerns
Substance Use Concerns
Immigration Issues
Other

Please specify:

Checkboxes *

Yes – I grant permission for Separation Pathways to share my responses internally with the professionals involved in my case (i.e. intake worker, mediator, lawyer, administrative staff.

** Separation Pathways would like to share your information with Family Professional Service Providers working with us. By choosing “Yes” below you are permitting Separation Pathways to share your information electronically with these partners involved in your case. We will never share your information with outside third parties.

The questions on this form are intended to support us in assisting you. Those with a (*) are required. Only answer others that you are comfortable answering.

-----

We will be in touch with you once we have received both parties intake questionnaires.

Cart