APPLICATION FOR PLACEMENT ON MEDIATOR LIST FOR REFERRALS FROM FAMILY COURT To be placed on the Approved Family Court Mediator List, an applicant must meet all requirements established by the West Virginia Supreme Court: 1. a 4-year degree from an accredited college or university; 2. completed a forty-hour family mediation course approved by the Supreme Court; 3. completed two observations of family court mediation sessions; 4. completed three co-mediation sessions with experienced family court mediators; 5. professional liability insurance; and 6. agree to complete twelve hours of family court mediator continuing education every two years. If you meet these requirements, please complete the following: I. General information Please print or type the following information: Name: Address: Daytime phone number: Fax number: E-mail address: Date form completed: II. College or University Education I have been awarded the following degree(s) from an accredited four-year institution: A. Check all applicable: Member of WV State Bar WV licensed social worker WV licensed psychologist WV licensed counsel or Other WV professional licensure, please provide details B. Date of licensure SCA-F-305 (Rev. 10/07) . . Application for Placement on Mediator List for Referral from Family Court Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com If you have not checked any of the above in A of this section regarding licensure, then you must complete the following. College or university: Degree awarded: Major emphasis of study: Year degree awarded: College or university: Degree awarded: Major emphasis of study: Year degree awarded: Please attach a copy of your diploma(s) or official transcript. III. Specific Family Law Mediation Training I have completed a forty-hour family mediation training course approved by the West Virginia Supreme Court. Yes No I completed this forty-hour training on the following date: The course of training was conducted by: in this city and state: Please attach a copy of your certificate for completion of this course of training. If you have not completed a forty-hour domestic relations course approved by the West Virginia Supreme Court for mediation training, the Court will consider for this purpose other training if you have been certified as a family mediator in another state: (1) (2) (3) (4) (5) (6) (7) IV. Attach to this application all documents and certifications verifying your training and status; List the number of family mediations that you have conducted; List the names of jurisdictions and contact persons in those jurisdictions who can verify your status; List the dates during which you conducted family mediations in those jurisdictions; List the dates, trainers, locations and descriptions of training you have received in West Virginia family law; List the dates, trainers, locations and descriptions of training you have received regarding the dynamics and other significant issues of domestic/family violence; and List the dates, trainers, locations and descriptions of training you have received regarding issues effecting the balance of power between parties in mediation. Observations of Family Court Mediation Sessions I have completed two observations of family court mediation sessions by experienced family court mediators. Yes No Observation No. 1: Mediator: Location: Date: Observation No. 2: Mediator: Location: Date: SCA-F-305 (Rev. 10/07) Application for Placement on Mediator List for Referral from Family Court Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com V. Co-mediation Sessions with Experienced Mediators I have completed three co-mediation sessions with experienced family court mediators. Yes No Co-mediation No. 1: Mediator: Location: Date: Co-mediation No. 2: Mediator: Location: Date: Co-mediation No. 3: Mediator: Location: Date: VI. Professional Liability Insurance. I have professional mediation malpractice liability insurance coverage. Yes No Insurance company: Policy Number: Time period covered by the policy: Type of coverage: Minimum coverage: $500,000/$500,000. You must notify the Family Court Services Division of the Supreme Court Administrative Office if your insurance coverage changes or is terminated. VII. Continuing Education in Family Court Mediation I agree complete a minimum of twelve hours of family court mediation continuing education training every two years, including the following: (1) eight hours of instruction in family court mediation; (2) two hours of skill development, demonstration, observation and evaluation; and (3) two hours of instruction and skill development in family court mediation ethics. The West Virginia Supreme Court of Appeals provides a two-day training every two years to satisfy this requirement. You may also send verification of completion of other continuing education to the Family Court Services Division of Administrative Office of the West Virginia Supreme Court of Appeals for consideration. VIII. Background information If you answer yes to any of the following, please include applicable dates and jurisdictions, in addition to providing a factual explanation. Have you had any misdemeanor convictions in the past five years? SCA-F-305 (Rev. 10/07) Application for Placement on Mediator List for Referral from Family Court Yes No Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com Have you ever been convicted of a felony, a domestic battery or assault, or other violent misdemeanor? Yes No Have you ever had your licence to practice law suspended or revoked? Yes No Have you had a family violence, domestic violence, or child abuse and neglect petition filed against you? Yes No Have ever had a family violence or domestic violence protective order entered against you? Yes No The West Virginia Supreme Court of Appeals may have you sign a release for the Court to conduct a background check to verify this information. IX. Other Requirements I agree to abide by the standards of practice established for family court mediation by the West Virginia Supreme Court of Appeals. Yes No There are facts about which I have knowledge that adversely bear upon my veracity, my qualifications, my ability and/or my fitness to properly, safely, and fairly mediate disputes. Yes No If the response to the above listed statement was “Yes”, I list those facts here: . I have never had my ability, privilege, license or right to mediate disputes revoked or canceled in any jurisdiction. Yes No I have mediated disputes and/or have applied for the right, privilege or license to mediate disputes in the following jurisdictions: X. . Agreement to Render a Proportional Number of Pro Bono Mediation Hours Please answer the following question, but an agreement to do pro bono mediation is not a mandatory requirement to be placed on the list. I agree to accept and mediate a number of cases referred by the West Virginia Family Court for no charge at a rate proportional to the percentage of pro bono cases within the Family Court Circuit(s) from Circuits within which I have applied to serve as a mediator. Yes No SCA-F-305 (Rev. 10/07) Application for Placement on Mediator List for Referral from Family Court Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com XI. Counties for Referrals Please list all of the counties in West Virginia in which you would like to receive referrals:_____________________________________________________________________ Please note that the Administrative Office will post your contact information on the county-bycounty list on the Supreme Court web site, but you will still need to contact the Family Court Judges from whom you would like to receive mediation referrals after you are approved. If you would prefer that your contact information be omitted from the list on the web site, please indicate here: Please do not include my name or any contact information on the county-by-county list on the Supreme Court web site. Please only include the following information on the county-by-county list on the Supreme Court web site: XII. Verification By signing this document, I hereby verify and swear that I have completed the above listed education, family court mediation observations and co-mediation sessions, that I have obtained professional malpractice insurance which provides the West Virginia Supreme Court required coverage and that all of the answers and responses which I have given on this application are true and accurate. Applicant Taken, sworn to and subscribed before me this day of . Notary Public Please send this completed this form, signed before a notary, and all required documentation to the following: West Virginia Supreme Court of Appeals Administrative Office Attention: Nikki Tennis Building 1, Room E-100 1900 Kanawha Blvd. East Charleston, WV 25305-0832. SCA-F-305 (Rev. 10/07) Application for Placement on Mediator List for Referral from Family Court Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com