Application for Mediation
CRITERIA FOR ACCEPTANCE OF AN APPLICATION FOR MEDIATION

MEDIATION FEE OF $400

The Domestic Relations Office (DRO) mediates for separating families that anticipate Divorce or desire to file a Suit Establishing the Parent Child Relationship (SAPCR) with the court. Mediation with the DRO provides a lower cost alternative to litigation by offering parents the ability to decide together what is best for them and their child(ren). Mediation is a process in which a neutral party (DRO) assists parents in resolving issues of parenting time.

AN EXECUTED MEDIATION AGREEMENT IS BINDING AND SHOULD BE PRESENTED TO THE COURT BY THE PARTIES FOR A FINAL ORDER TO BE ISSUED.

To be eligible for this service, the parties’ combined annual income should be $75,000 or less a year and the current situation between the parties must be appropriate for mediation. The Court may order mediation or the parties may agree to mediate by completing this application and submitting it to the DRO.

The Mediation fee of $400 can be paid by both parties paying $200, but the entire fee must be paid prior to commencement of services.

Parties participating in Mediation services are required to complete the online Mediation Orientation.

Upon approval of the application, DRO will provide additional information to each party regarding the process and will also request more information regarding the issues to be mediated.

I certify that I have read, understood and agree to abide by the terms of these criteria.


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Email *
Cause Number: *
Mother's name (Petitioner or Respondent): *
Home phone: *
Employer phone number: *
Address (include city, state and zip code): *
Date of Birth: *
Last 4 digits of social security number: *
Occupation: *
Gross Income/yr: *
Attorney name, phone number, fax, e-mail:
Father's name (Petitioner or Respondent) *
Home phone: *
Employer phone number: *
Address (include city, state and zip code): *
Date of Birth: *
Last 4 digits of social security number: *
Occupation: *
Gross Income/yr: *
Attorney name, phone number, fax, e-mail:
Other:                                                                                                                                                                              Name:
Relationship to child(ren):
Home phone: *
Employer phone number: *
Address (include city, state and zip code): *
Date of Birth: *
Last 4 digits of your social security number: *
Occupation: *
Gross Income/yr: *
Attorney name, phone number, fax, e-mail: *
Ad Litem:                                                                            Name:
Home phone:
Fax:
Child 1 Full name, Date of Birth and last 4 of SSN *
Child 2 Full name, Date of Birth and last 4 of SSN *
Child 3 Full name, Date of Birth and last 4 of SSN: *
Is the Office of Attorney General involved in this case? *
Case type: *
Date of Marriage: *
Date of Separation: *
Temporary Orders *
Date of Temporary Orders:
Child(ren) residing with (mother, father, or if other, specify): *
What are the issues to be mediated? Custody/Possession/Child Support/Property/Other (Please Explain): *
Are there any allegations of Domestic Violence (within last 12 months)? *
Are there any allegations of Drug/Alcohol Abuse (within last 12 months)? *
CURRENT Protective Order? *
Open CPS case? *
Is there a registered sex offender in the household? *
IF YOU CHOSE YES TO ANY OF THE ABOVE QUESTIONS, PLEASE DISCUSS YOUR CONCERNS WITH THE DRO REGARDING THE ABILITY TO SUCCESSFULLY MEDIATE.
Are you currently receiving victim services? *
Are you currently receiving BIPP services? *
Are you currently on any medication? *
If taking medication, does it impair your ability to make decisions?
Clear selection
Do you have any concerns being in the same room with the other parent? *
If yes to above question, do you agree to mediate in separate rooms?
Clear selection
On a scale of 1 to 10, what best describes your level of concern for your physical safety? *
No concern
Very Concerned
Person completing this Form: *
Date of Application: *
Submit
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