Mediator Report (02/04/16) CCDR 0047 IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, DOMESTIC RELATIONS DIVISION MEDIATOR REPORT (The mediator must submit this report to the Office of the Presiding Judge of the Domestic Relations Division within seven (7) days of completing mediation or determining that mediation is not appropriate.) Mediator Name: _______________________________ Referring Judge: _______________________________ 1. Type of case: a. Divorce b. Paternity e. Child Support 3. I was 4. 3409 3410 f. Post-judgment Case Number: _____________________________________ Petitioner/Respondent Name: _________________________ d. Guardianship g. Other: __________________________________ c. Allocation of Parental Responsibilties 2. This case/relevant petition was filed on (date, if known): _______/_______/_______ a. selected by parties b. appointed by the Court as the Mediator in this matter on (date): _______/_______/_______ Mediation: A. Was not completed because: 3411 1. Mediator was told the parties reached an agreement outside of mediation 3412 2. One or both parties failed to attend 3413 3. Mediation was found to be not appropriate at this time 3414 4. Other reason: ________________________________________________________________ B. Took place: Date began: _______/_______/_______ Date ended: _______/_______/_______ Number of sessions: _______ Total hours in mediation for all sessions: _______ Hours of preparation: _______ Fee / Rate per hour or case: $ _______________ Total amount: $ ____________ C. Has been continued 5. Participants to the mediation: a. Petitioner d. Respondent b. Petitioner's attorney e. Respondent's attorney c. Child(ren): (number) ________ f. Guardian ad litem 6. Issues mediated/ended in: (Check all that apply.) (1) Full Agreement a. Allocation of Parental Responsibilities 3431 b. Parenting Time 3451 c. Visitation (Non Parent) 3454 d. Relocation 3421 e. Financial (child related) 3427 f. Financial (non-child related) 3436 g. Maintenance 3439 h. Other: ______________ 3442 g. Step-Parent(s): (number) ________ h. Other: _____________________ (2) Partial Agreement 3432 3452 3455 3422 3428 3437 3440 3443 (3) No Agreement 3433 3453 3456 3423 3429 3438 3441 3444 7. Interpreter Needed: 3446 a. No or b. No because Mediator spoke the language: ____________________________ 3445 c. Yes (Language requested: _______________________________________________________ ) If yes: 3447 d. Requested and provided or 3448 e. Requested and not provided Signed: ____________________________________________ Date: __________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com