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Request for Mediation

First Name:

Last Name:

Case No.

Your relationship to the child(ren):

Your mailing address (House, City, State, Zip):

Is your mailing address private?

Is your telephone number private?

Your telephone number:

Your email address:

Name of other party:

His/her relationship to the child(ren):

Mailing address for the other party (House, City, State, Zip):

Telephone number for the other party:

Email address for the other party:

Why are you requesting mediation?

Change of Residential Parent for School Purposes
Modification of Custody/Parenting Time
Other... This choice will expand a text box

Is mediation court ordered in a prior entry?

Has a motion been filed?

Name and birth dates of minor child(ren) in this case.

Name:

Date of Birth:

Name:

Date of Birth:

Name:

Date of Birth:

Name:

Date of Birth:

With whom are the child(ren) living?

Is there a Restraining Order or a Civil Protection Order currently in effect?

Issued by?

Have you notified the other party of your request for mediation?

By submitting this form you are authorizing the Court to contact the other party (Respondent or Petitioner) regarding your request for mediation services and what you are requesting to be modified. By submitting this form you acknowledge that Mediation services are voluntary by both parties and said services may be denied by the court for any reason.

Request for Mediation

Name and birth dates of minor child(ren) in this case.

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