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Fill and Sign the Please Fill in the Circle Z that Best Reflects Your Form

Fill and Sign the Please Fill in the Circle Z that Best Reflects Your Form

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Cour t N ame: Ca se Nam e: Ca se Num ber: (if k now n) THE ST A TE O F NEW H A M PSHIRE JUDI CI AL BR AN C H M EDI ATIO N QUESTI O NN AIRE MEDIATOR DA TE OF ME DIAT ION I a m : { Petitio ner { R espo nde nt { Attor ney for Petiti on er { Attor ney for Resp onde nt Plea se f ill in the c ircl e z tha t be st reflects you r opinion of the med iat or’s performan ce in each area Strongl y Agree Agree Not Sure Disagre e Strongl y Disagre e 1. The m ediator ex plain ed the m ediati on proc es s clear ly so t hat I kne w what to ex pec t dur ing th e m ediati on s es sion. { { { { { 2. The m ediator was im par tia l an d tr eated al l par ties equ ally. { { { { { 3. The m ediator ga ve m e an o ppor tuni ty to f ully ex pla in t he dis pute. { { { { { 4. The m ediator listene d t o an d un der stoo d m y per spec tives . { { { { { 5. The m ediator was ab le to f ac ilitat e d iscus sion su cce ssfully. { { { { { 6. The m ediator hel pe d u s ex plor e dif ferent opti ons to res olve the dis pute. { { { { { 7. Med iation sav ed t ime and/or m one y in this ca se . { { { { { 8 Overall, I was satisfied with the wa y th e mediator han dled t he c as e and t he m ediat ion proc es s. { { { { { 9. I wou ld c ons ider m ediation for other m atter s. { { { { { 10. I wou ld us e th is m ediat or aga in or rec om mend him or her to o ther s. { { { { { 11. Me diation h ad the fo llow ing im pact on this case : (Fill a ll th at ap ply.) { settle d th e cas e { cl ar ified p ositions of the par ties { settle d so m e of the issues { no i m pact { sig nifican tly m oved the c ase t oward settle m en t { oth er 12. At w hat sta ge in the case d id th e me diation sessio n take place? (Fill a ll th at a pply.) { be for e any for m al c our t h ear ing { a fter sev eral hear ings { a fter a Temp or ar y H ear ing { a fter the Fi nal Pr etrial C onfer ence { a fter a Pr elim inar y H ear ing { unsur e NHJ B-2091-F S (04 /24/ 2006) Page 1 o f 2 Case Name: Case Nu mber: MEDI ATION QUE STIONNA IRE 13. I feel the case w as r efer red to m edi ati on: { too ear ly { at abo ut t he r ight ti me { too late 14. If th e medi ation w as not succ ess ful, w hich o f the fol lowing reasons best ex plains w hy? { peti tioner failed t o p ar ticipate { lack o f trust i n ot her par ty { r espo nde nt fai led t o par ticipat e { att orney adv ice to r esist r esol ution { me diator not hel pful { do mesti c violence past or pr esen t { me diati on to o l ate in pr ocess { me diati on to o e arly in pr ocess { oth er 15. W hat di d th e m edi ator do w ell dur ing your me diati on sessi on ? W hat co uld t he me diator hav e do ne bet ter during the m edi ati on s es sion? 16. W hat do y ou l ike a bou t the me diati on pr og ram? How woul d y ou chang e th e m edi ation pr og ram? 17. If y ou chos e n ot to obtain legal repr es ent ati on, di d th e m edi ator advise y ou tha t an indep end ent att orney shoul d review your ag reeme nt be for e it is si gned? Please plac e q uestio nnaire i n s ealed e nvelo pe and gi ve to m ed iator to be ret urne d to court s taff NHJ B-2091-F S (04 /24/ 2006) Page 2 o f 2

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  • 5.Utilize the ✔ key, then tap on the Save option to finish editing.

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