NORTH CAROLINA COUNTY OF WAKE IN THE GENERAL COURT OF JUSTICE DISTRICT COURT DIVISION FILE NO. ____________________________ Assigned Judge:_______________________ ___________________________________, Plaintiff, v. ___________________________________, Defendant. CUSTODY MEDIATION COVER SHEET 1. Have the parties previously attended a group orientation? YES NO 2. Have the parties previously attended custody/visitation mediation? YES NO 3. Is there a pending or resolved civil or criminal domestic violence case involving the same parties in North Carolina or any other State? YES NO If yes, you must attach a copy of all civil or criminal domestic violence restraining orders. 4. Do either of the parties need an interpreter to be present at the group orientation and/or mediation session? YES NO If yes, what language(s) does the party speak? _______________________________________ Instructions: please COMPLETELY fill out the contact information for both parties and attorneys Plaintiff’s Address: Defendant’s Address: Plaintiff’s Telephone Number (optional): Defendant’s Telephone Number (optional): Plaintiff’s Email Address (optional): Defendant’s Email Address (optional): Attorney for Plaintiff’s Name and Address: Attorney for Defendant’s Name and Address: Attorney for Plaintiff’s Telephone Number: Attorney for Defendant’s Telephone Number: Date: _____________ ________________________________________________________ Plaintiff Defendant Attorney for Plaintiff Attorney for Defendant CUSTODY MEDIATION/FAMILY COURT OFFICE USE ONLY Orientation Date: Mediation Date: WAKE-DOM-06 Page 1 of 1 (Rev. 02/10) American LegalNet, Inc. www.FormsWorkFlow.com