Mediator Report Template
Download a blank fillable Mediator Report Template in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Mediator Report Template with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Print Form
MEDIATOR REPORT
Mediator Name: _________________________________________ Case No. _________________
(please print)
Referring Judge: _______________________
Case Name:___________________________
LaSalle
County of: _____________
1. Type of case:
Divorce
Paternity
Post-judgment
Family
Guardianship
Other ___________________________________
2. This case / relevant petition was filed on (date, if known): _____/_____/_____
3. I was:
selected by the parties
appointed by the Court as the Mediator in this matter on (date): _____/_____/_____
4. Mediation:
A.
Was not held because:
[
] An agreement was reached prior to mediation
[
] One or both parties failed to attend
[
] An impediment was found to exist
[
] Other reason _______________________________________________________
B.
Took place
Date began: _____/_____/_____ Date ended: _____/_____/_____
Number of sessions: ______
Total hours in mediation for all sessions: _______ Hours of preparation: _______
Fee / Rate per hour or case: $ ________________ Total amount: $ ________________
C.
Has been continued
5. Participants to the mediation:
Mother
Father
Guardian ad litem
Mother’s Attorney
Father’s Attorney
Step-Parent/s: (number) _____
Children: (number) _____
6. Issues mediated / ended in:
Full Agreement
Partial Agreement
No Agreement
(Check all that apply)
Significant Decision
making Responsibilities
[
]
[
]
[
]
Parenting Time
[
]
[
]
[
]
Relocation
[
]
[
]
[
]
7. Interpreter Needed:
No
Yes
If yes:
Requested and provided
Requested and not provided
Signed: ________________________________________________ Date: ____________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal