Mediation Grant Data Collection Form {NHJB-2752-F}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p ://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) MEDIATION GRANT DATA COLLECTION FORM Thank you for participating in mediation. One or both parties qualified to have their mediation fee paid for by a grant the Court receives from the Department of Health and Human Services (DHHS). DHHS asks that we collect data to help them improve services. All questions are optional and are not used to identify you; the data will be reported to DHHS in a group with others who qualified for the grant. I am the Petitioner Father Mother Respondent Father Mother What was the status of your relationship with the other party at the time of this mediation? Never Married To Each Other Separated From Each Other Divorced From Each Other Married to Each Other How many children do you have in common? For how many of those children do you have: any parenting time? equal parenting time? Did your parenting time increase through this mediation? Yes No I identify as (check all that apply) American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White Two or More Races My gross income is Less than $10,000 $10,000 - $19,999 $20,000 - $29,999 $30,000 - $39,999 $40,000 and above FOR MEDIATOR ONLY Did you provide any parent with information about additional resources? Yes No Was a parenting plan (temporary or permanent) created during this session? Yes No Was child support an issue during this session? Yes No NHJB-2752-F (02/01/2019) American LegalNet, Inc. www.FormsWorkFlow.com