Request For Mediation And Order (Family Law Case)
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1IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF DESCHUTES
_____________________________________________, )
Petitioner,
)
)
)
Case No._____________________
and
)
)
REQUEST FOR MEDIATION
)
AND ORDER
_____________________________________________, )
(FAMILY LAW CASE)
Respondent.
)
( )Co-Petitioner
I,____________________________________________, am the (mother) (father) of the child(ren) in this matter. We do not
agree on custody and/or parenting time and I am therefore requesting that the Court send us to a mediator. I will take
responsibility to see that the other parent receives a copy of this request as indicated in the “Notice” section below.
[ ] A restraining order is currently pending
[ ] I have concerns regarding my personal safety
Signed: ________________________________________
Date: _______________________
(Parent)
TO BOTH PARENTS: You must promptly contact the Deschutes County Mental Health Department Mediation Program,
th
(541) 385-1719 at the Rosie Bareis Community Center, 1010 N.W. 14
Street, Bend, OR 97701 to schedule a Mediation
Orientation appointment. Inform the Mediation Program staff about any Restraining Order and/or any personal safety
concerns you may have. You must contact the Mediation Program within (7) days of the date this form was mailed or given
to the other parent.
[ ] Request is denied
IT IS SO ORDERED: _________________________________
Date: ______________________
Circuit Court Judge
Notice to parents making this request: The Court requires you to give notice to the other parent.
I certify that I gave or mailed a copy of this Request to the other parent or the parent's attorney
on_______________( date ) .
Certificate of Document Preparation. You are required to truthfully complete this certificate regarding the document you
are filing with the Court. Check all boxes and complete all blanks that apply:
[ ] I selected this document for myself and I completed it without paid assistance.
[ ] I paid or will pay money to________________________for assistance in preparing this form.
Signed: ______________________________________
Date: ______________________
Submitted by:
_____________________________________________________________________________________________
[ ] Petitioner [ ] Respondent,
Print Name
Address or Contact Address
_____________________________________________________________________________________________
Telephone or Contact Telephone
City, State, Zip
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