Center for Family & Divorce Mediation

- a not-for-profit corporation-

Townhouse B
111 West 90th Street
New York, NY  10024


Suite 300
2 New Hempstead Road
New City, NY  10956


(212) 799-4302
Fax 723-1012

(845) 638-4666
Fax: 634-1675

We have voluntarily retained the Center for Family & Divorce Mediation (The Center) to conduct family and/or divorce mediation with us.  We have not waived our rights to consult with and/or retain our own attorneys concerning this or any other matter.  The Center also in no way requests that we waive this right.  We further understand that each of us is free to consult with and/or retain our own independent attorney at any point in the mediation process.  If we do not do this at any particular time, it is by our own choice.  The Center has made it clear that it recommends that each of us consult with independent attorneys before signing any Separation Agreement.  We understand that this agreement does not bind us to continue to work with The Center.


The Center, the mediator and the parties further agree with one another as follows:

A.   Mediation is a voluntary procedure.  We are undertaking it to reach a settlement of a dispute between us, the parties.  This voluntary procedure depends on the development of trust from increasing openness and risk taking.  As a result, everyone involved in mediation, and the mediation process itself, needs the protection offered by complete confidentiality.

B.   We agree that all communications between the parties and the mediator about the dispute come within the rules of evidence, which exclude from court or arbitration, any disclosures made with a view towards settlement.

C.   The parties agree that they will not call the mediator or any consultant brought in by The Center as a witness in any court or arbitration to testify regarding any aspect of the mediation.  The parties shall not require the production in court or arbitration of any records or documents made by the mediator or any consultant brought in by The Center.

Our fee is $             per hour, or prorated parts of an hour.  Fees will be paid at each session.  This fee is for: mediation sessions, telephone contacts with us or other professionals concerning our mediation, or researching, preparing and drafting written materials.  No work will be done without our consent.

We understand that consultants may be required to handle specialized tasks.  The charges of those consultants will be separate and in addition to fees charged by The Center.  These separate fees will be discussed with us beforehand and billed directly to us by these professionals.

If the mediator is also an attorney, we agree that the mediator-attorney will not represent either party in an adversarial court case.  We also agree that the preparation and filling of uncontested divorce papers is not an adversarial court case.

This agreement is contractual and cannot be changed or waived without the written consent of The Center, the mediator, and the parties.

Consented and Agreed to by the Parties:







Glenn E. Dornfeld

For The Center for Family & Divorce Mediation



Center for Family & Divorce Mediation

- a not-for-profit corporation-

Townhouse B
111 West 90th Street
New York, NY  10024


Suite 300
2 New Hempstead Road
New City, NY  10956


(212) 799-4302
Fax 723-1012

(845) 638-4666
Fax: 634-1675

Name:   Harry Home Phone:
Work Phone:  
Maiden Name (if any): Place of Birth:
Home Address:   Westchester Date of Birth:   1965
                            New York Social Security #:
Education: HS: Some College: MA:     X Graduated School (Type):
Marriage Date:  1987 Place: Civil: Religious:     X

Children from present marriage and step children living in household:

Full Name Date of Birth School Grade
Amy                                     89                                                                                9
George                                 95                                                                                3

Do any of the children have special education or special medical needs?


What best describes your children's knowledge of your marital situation?

  they know nothing
  they know that something is happening


they know that we are separating
  they think we are tying to work things out
  they know that we are definitely getting divorced


Do you anticipate a dispute about custody of the children? Yes: No:     X Possibly:


Who initiated the idea of separation or divorce? Self:        X Spouse:


What was your spouse's reaction:     Bad


Are you presently living with your spouse? Yes: No:       X
If not, when did you separate? 4 months ago, Thanksgiving  
If not living together, who initiated? Self: Spouse: Mutual:     X


Whose idea was starting divorce mediation? Self: Spouse: Mutual:


Who referred you to The Center? Carl, our friend


What best Describes your current situation:

  I want to reconcile and stay married
  I don't know what I want
  I want a trial Separation
  I want a legal separation followed by a divorce


I want a divorce as quickly as possible
  Not clear if I want to get divorced

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

A marriage counselor or therapist who both you and spouse saw: N/A
An individual therapist who you have seen or presently see: N/A
An attorney who you contacted separation or divorce: N/A


Your Occupation:     Financial Planner Job Title:
Name of Employer: Work Address:



How long at present job:     12 years
Gross Salary: $350- per:    year Other regular income:
Does your employer provide?  Medical Insurance:   Yes Life Insurance:  Yes  
Pension: Savings Plan: Stock Rights: 401K Plan:   Yes Other:

Do you have any of the following?

House:     X Vacation Home:  X Boat: Antiques: Collectibles:
Business (describe):
Cars (describe):    Volvo 22K  &  Lincoln Continental lease at $750/month
Bank Accounts: Checking:    $20,000 joint Savings:   $50,000 joint
Investments: Stocks:   100,000 Bonds:  50,000 Mutual Fund:  100,000 Other: 2 529's @ 25K each
Private Retirement: IRA:   100,000 me, 70,000 Wendy Keough: Other:

Please list any major debts:

Mortgage - $200.000
Credit Cards - $22,000   (joint account - Wendy's charges)

Household finances have been primarily handled by:

Self: Spouse: Mutual:    X - Wendy does bookkeeping

List below any prior marriages an indicate if there are any children, their ages, and who they live with.

Please describe any financial arrangements between you and your former spouse:



Are there any other facts or circumstances that are relevant to your seeking mediation at this time?

I have a girlfriend and want out quick.  Rachel (27 years old)
Condo costs 10K a month.
I am now renting a 3 bedroom apartment for $3K a month, don't want to for long.


Harry's Offer

Joint Harry Wendy  
FL Condo Live paid upkeep for 5 years $750,000 (not in mix) Monthly $850.00
House - $850,000   $650,000 <you pay mortgage>


$2,500, includes tax & Insurance
401K 500,000 50,000  
IRA 100,000 50,000  
Stocks - 100,000 50,000 50,000  
Bonds - 50,000 50,000    
Mutual Funds - 100,000 50,000 50,000  
Bank - 80,000 40,000 40,000  
529 Amy 25,000 <Not in Mix>
529 George 25,000 <Not in Mix>
Collectibles 20,000    
Car - Volvo   22,000  
  Buy-Sell $1,000,000    
Credit Cards - 22,000   22,000  
Life Insurance, Term $1,500,000 $250,000  
Salary $350,000 $40,000 from Harry's firm (no real work anymore)

$10,000 Interior Design