Family Mediator Certificate of Attendance and Status Report

Thank You

Thank you for completing this certificate of attendance and survey. Your information is very valuable. The mediator responses to this form are compiled and reported to the District Court Judges, the Iowa Judicial Branch, the committee that oversees the Family Mediation Program (MAC), and are posted on the MSEI website: mediateiowa.org. These responses inform critical decisions on process improvement.

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* 1. Your name

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* 2. Second mediator (if present)

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* 3. Names of parties

Name 1

Name 2

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* 4. I certify that the above parties attended an initial mediation session with me.

Yes

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* 5. Date of Mediation

Date

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* 6. Case Number

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* 7. County where case is filed

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* 8. Court-ordered mediation?

Yes

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* 9. Default mediator?

Yes

Don't Know

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* 10. Number of sessions

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* 11. Total number of hours mediating

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* 12. Did the parties reach agreement on:

No issues

Some issues

All issues

Uncertain because mediation is ongoing

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* 13. The issues mediated were:

For a temporary order or orders

For a final order or decree

For a modification order

Parenting Schedule: custody and/or visitation

Alimony/Spousal support issues

Child support/Medical support

Distribution of assets or debts or other financial issues

Lack of compliance with previous court orders (contempts)

Not listed

Other (please specify)

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* 14. Were attorneys present at any session?

Yes

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* 15. Did you screen for domestic violence?

Yes

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* 16. Comments

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