Mediation Screening Form

Mediation Screening Form

This Mediation Screening Form is submitted by Party A: and Party B: concerning Case Number: . Completion of this form is for the mediator's screening purposes; submission does not itself constitute an agreement to mediate nor waiver of any rights unless and until a separate mediation agreement is executed.

RECITALS

WHEREAS, the parties seek to determine whether the matter described below is appropriate for mediation and to provide the mediator with material information relevant to safety, representation, and settlement authority; and

WHEREAS, the parties acknowledge that the mediator may decline to accept the matter for mediation, may require precautions or separate session procedures, and may condition acceptance on execution of additional agreements; and

WHEREAS, the parties agree to provide accurate information in this screening form and understand that material omissions or misrepresentations may affect the mediator's decision to proceed.

NOW THEREFORE, the parties provide the following information for the purpose of screening this matter for mediation.

1. CONTACT AND REPRESENTATION

2. CASE AND DISPUTE DETAILS

3. PRIOR ADR AND SETTLEMENT-EFFORTS

Prior settlement efforts: Settlement conference Prior mediation Arbitration Other

4. SAFETY, POWER IMBALANCE, AND SEPARATE SESSIONS

Are there any current or past restraining orders, protective orders, criminal charges, or documented threats between the parties? Yes No

Do any parties request separate caucus sessions or shuttled mediation due to safety, power imbalance, or trauma? Yes No

5. CONFIDENTIALITY, PRIVILEGE, AND DOCUMENTS

The parties acknowledge that mediation communications will be treated as confidential as required by applicable law and that the mediator will not, except as required by law, disclose mediation communications. The parties further acknowledge that privilege issues, preservation of evidence, and mandatory reporting obligations (e.g., threats of imminent harm, abuse of minors) may limit confidentiality.

Party A acknowledges and agrees to confidentiality terms: . Party B acknowledges and agrees to confidentiality terms: .

6. COUNSEL, SETTLEMENT AUTHORITY, AND DECISION-MAKERS

Is the party represented by counsel? Party A: Yes No . Party B: Yes No

7. ACCESSIBILITY, INTERPRETERS, AND ACCOMMODATIONS

Interpreter required? Yes No . If yes, language:

8. FEES, DEPOSITS, AND CANCELLATION

Proposed fee arrangement: Mediator fee to be divided as follows — Party A pays ; Party B pays . Cancellation policy:

9. ISSUES, GOALS, AND RELIEF SOUGHT

10. CONFLICT DISCLOSURES AND OTHER INFORMATION

11. NOTICE, AMENDMENTS, WAIVER

Notices provided under this screening process shall be effective when delivered to the contact information set forth above. Any amendment or waiver of the statements in this form must be in writing and signed by the party granting the waiver or amendment. Failure to insist upon strict compliance with any term here shall not constitute a waiver of future enforcement.

12. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY; COUNTERPARTS

This screening form shall be governed by the substantive law applicable to the underlying dispute and shall not be construed to modify substantive rights outside the mediation process. This form contains the parties' entire understanding with respect to mediation screening matters and supersedes all prior oral statements regarding the same. If any provision is held invalid, the remaining provisions shall remain in full force. This form may be executed in counterparts, each of which shall be deemed an original.

13. CERTIFICATION

By signing below, each party certifies that the information provided in this form is true and accurate to the best of that party's knowledge, that the party has disclosed any safety risks or legal impediments to mediation, and that the party understands the limits of confidentiality as described above.

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