L. R. Prac. Sup. Ct. DR app B

As amended through August 22, 2024

Appendix B - Private Mediation Roster Application

NOTE: Information disclosed on this Registration Form might be considered public record.

PART I--General Information

1.		BUSINESS LOCATION AND HOURS:

	A.	Name:_________________________________________

	B.	Address:_______________________________________

	C.	Telephone:______________	Pager/Mobile:_______________	Fax:___________

	D.	Office Days and Hours:__________________________

	E.	Other Office Location(s):________________________

	F.	Address:___________________________

	G.	Telephone: __________________	Fax:_________________

	H.	Office Days and Hours:______________________________________

2.	FEES FOR SERVICES:

	A.	What do you charge for an Initial Consultation? 1/2 Hour $ _____; Hour $_______________

	B.	What is your hourly charge for services? $

	C.	How do you require payment to be made? [ ] Cash [ ] Personal Check [ ] Credit Card (list which ones):
	_____________________________________________________

	D.	When do you require payment for services to be made? [ ] At time service is performed [ ] At end of all services to be performed [ ] Other (Please explain):

	______________________________________________

	E.	Do you require a retainer? If so, please describe____________________________________________

3.		LANGUAGE FLUENCY: Please list all languages in which you are fluent:

		[ ] English [ ] Spanish [ ] Other (please list):__________________________________________________

		Please indicate if staff in your office is fluent in other languages.

		Please list:____________________________________

4.		EDUCATION AND TRAINING:

	A.	EDUCATION: Please attach a transcript or a copy of your diploma for each degree listed.

		DEGREE AWARDED:	DATE RECEIVED:	INSTITUTION:
		_____________________	_____________________	_____________________
		_____________________	_____________________	_____________________
		_____________________	_____________________	_____________________
		_____________________	_____________________	_____________________
	B.	MEDIATION AND OTHER REQUIRED TRAINING

	(Must include a 40 hour basic mediation training for the general roster; an additional 40 hour domestic relations mediation training for the family mediation roster; 12 hours of child abuse training and 12 hours of domestic violence training for the family mediation roster.)

	List (1) the name of training attended, (2) the dates of attendance, and (3) the institution conducting training.

	1.	___________________________________________________

		___________________________________________________

	2.	___________________________________________________

		___________________________________________________

	3.	___________________________________________________

		___________________________________________________

	C.	APPLICABLE MEMBERSHIPS, LICENSURE, CREDENTIALS

	1.	___________________________________________________

		___________________________________________________

	2.	___________________________________________________

		___________________________________________________

	3.	___________________________________________________

		___________________________________________________

5.	MEDIATION EXPERIENCE:

	1.	___________________________________________________

		___________________________________________________

	2.	___________________________________________________

		___________________________________________________

	3.	___________________________________________________

		___________________________________________________

6.	PROFESSIONAL LIABILITY INSURANCE:

	Do you have Professional Mediator Liability Insurance? [ ] YES [ ] NO

	Provider: _______________

	Policy Number: _______________

	Coverage Limits: _______________

7.	OTHER MATTERS:

	A.	Have you been arrested, charged or convicted of a felony, or have you been arrested, charged or convicted of any matter relating to sexual misconduct, regardless of when such arrest, charge or conviction occurred?

		[ ] NO [ ] YES (If yes, please attach explanation.)

	B.	In the past three years before submitting the Registration Form, have you had an adverse decision rendered against you by any regulating agency or court pertaining to the service or conduct which is related to the services that are the subject of the Court Roster?

		[ ] NO [ ] YES (If yes, please attach explanation.)

	C.	Are you under any current limitations by any regulating agency or court pertaining to the service or conduct which is related to the services that are the subject of the Court Roster?

		[ ] NO [ ] YES (If yes, please attach explanation.)

	D.	Do you know of any present or past conduct that might or may affect your ability to provide the service or conduct which is related to the services that are the subject of the Court Roster for which you are applying?

		[ ] NO [ ] YES (If yes, please attach explanation.)

PART II. Family Mediation Information

EXPERIENCE

Please check the following option that best describes your experience as a family mediator:

	[ ]	I have a minimum of two (2) years experience as a family mediator, with a minimum of 20 cases mediated,

		OR

	[ ]	I have one (1) year of experience as a family mediator with a minimum of 10 cases mediated or two (2) years experience as a general mediator. I understand that if I qualify under this option, I must be willing to conduct two family mediations under supervision and direction of the Mohave County Superior Court, Conciliation Court Services, Alternative Dispute Resolution (ADR) Administrator or an approved Family Mediation Roster Member and provide a written recommendation from said member to the ADR Administrator before accepting referrals from the Court to act as a mediator in family cases.

Please explain your experience as a family/general mediator below, including number of years you've been mediating and the approximate number of FAMILY cases you have mediated.
___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

___________________________________________________

Number of family cases mediated: __________

EDUCATION/ TRAINING

	1.	[ ] YES [ ] NO	I have completed an approved 40 HOUR COURSE in family, domestic relations, or divorce mediation.

		OR

		[ ] YES [ ] NO	I have completed an approved 40-hour basic mediation training PLUS an approved 20-hour advanced family mediation training that includes training in family violence?

			Date of course: _______________

			Institute or Agency: _______________
			(Attach copy of certificate of attendance to this Registration Form.)

	2.	[ ] YES [ ] NO	I have provided proof of twelve (12) hours training in family violence issues and twelve (12) hours of training in child abuse issues.

	3.	[ ] YES [ ] NO	I will complete a minimum of five (5) hours of continuing education credits each calendar year in alternative dispute resolution (ADR) topics, including at least one (1) hour every two years on domestic violence issues and one (1) hour every two years on child abuse issues. (You must submit proof of completion to the Superior Court ADR Office prior to December 15^th of each year.)

	4.	[ ] YES [ ] NO	I maintain separate mediator liability insurance on a continuous basis. (You must submit proof of mediator liability insurance to the Superior Court ADR Office and annually provide proof of coverage on or before the policy renewal date, but no later than December 15^th of each year).

	5.	[ ] YES [ ] NO	Do you have at least a master's level of graduate degree in a social science, a juris doctorate degree or related degree in a related field?

MEDIATION EXPERIENCE

	1.	How many years have you been mediating cases as a third party neutral? _______________

	2.	Estimate the number of cases you have mediated as a third party neutral._______________

	3.	How many years have you been active in practice as a FAMILY mediator?_______________

	4.	How many years of experience do you have in FAMILY cases or practice, other than in mediation?_______________

PREFERRED MEDIATION AREAS

	1.	What types of cases in FAMILY mediation are you willing to mediate:

		_____Divorce, Legal Separation, Annulment

		_____Grandparent Rights

		_____Paternity

		_____Post-Decree Matters

		_____Adoption, Juvenile Dependency

	2.	[ ] YES [ ] NO	Are there any kinds of cases you prefer NOT to handle as a FAMILY MEDIATOR? If YES, please describe:________________________________

			__________________________________

ROSTER CERTIFICATION REQUIREMENTS

If I am included in the Mohave County Superior Court Family Court Mediator Roster, I WILL:

	[ ] YES [ ] NO	Submit proof of all mediation experience, education and training requirements as established by the Superior Court?

	[ ] YES [ ] NO	Submit initial and continuing proof of compliance with continuing education or special training requirements as established by the Superior Court?

	[ ] YES [ ] NO	Submit initial and continuing proof of mediator liability insurance in accordance with Superior Court procedures?

	[ ] YES [ ] NO	Attend a Family Court Mediator Roster orientation prior to acceptance of any cases from the Superior Court?

	[ ] YES [ ] NO	Conduct pre-mediation screening as to appropriateness of mediation services for the case, including domestic violence screening? (A sample screening form is available.)

	[ ] YES [ ] NO	Submit copies of case screening methods, including domestic violence, to be used in determining appropriateness for mediation?

	[ ] YES [ ] NO	Adhere to Models and Standards of Practice for Mediators established by the Association of Family and Conciliation Courts?

	[ ] YES [ ] NO	Adhere to all ethical standards set by the Superior Court?

	[ ] YES [ ] NO	Annually complete one pro bono mediation for every two cases referred to me by the Superior Court for which I am compensated?

	[ ] YES [ ] NO	Comply with all reporting requirements, including grievance and feedback procedures, adopted by the Superior Court.

I swear that all of the information on this registration form, and any attached subparts, is true and accurate to the best of my knowledge, information, and belief. I have read and I understand the requirements and agree to abide by them. I will advise the Court in writing of any material changes to the information contained in this Registration. I understand that failure to be truthful about matters related to this application or to abide by these Policies and Procedures may result in the removal of my name from the applicable Court Roster.

Signature:___________________________________

Subscribed and sworn to before me this ___ day of _____, ___

by _____.

Signature____________________________________

Notary Public

My commission expires:_________________________

L. R. Prac. Sup. Ct. DR app B

Revised 6/16/06. Amended June 30, 2009, effective 1/1/2010.