Page1 / 3

Statewide Civil, General Equity and Probate Mediation Program

Mediation Case Information Form

Directions: This form is to be completed by the mediator when the mediation is concluded or returned to court.

Case Docket Number (e.g. L-000067-10)

Name of Mediator

Outcome/Nature of Agreement

Number of mediation sessions

Number of hours of preparation time

Number of hours in sessions

Number of hours billed to the parties

At what stage in the case did the mediation sessions take place? (note all that are applicable)