IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT COUNTY, ILLINOIS Petitioner, vs. Case No: Respondent. ORDER OF REFERRAL TO MEDIATION (Local Court Rule G-5.B.3) Pursuant to Local Rule G-5.B the parties are ordered to participate in mediation. The Mediator [ ] agreed upon by the parties [ ] ordered by the Court is: Name Address Telephone Fax Issue(s) to be mediated: [ [ [ [ ] Initial Custody [ ] Modification of custody ] Visitation schedule [ ] Visitation abuse issues pursuant to 750 ILCS 5/607.1 ] Removal from state [ ] Joint custody pursuant to 750 ILCS 5/602.1 ] Other non-economic issues relating to the children (specify): [ ] Economic issues involving the parties (specify): First Status Date (within 45 days): Order to Initial Mediation: The parties are ordered to contact the mediator within 3 business days of this order and shall schedule an orientation session with the mediator as soon as can be reasonably scheduled. Party A: Name of Party Address of Party Attorney for Party Attorney's Address Telephone Telephone Fax Party B: Name of Party Address of Party Attorney for Party Attorney's Address Telephone Telephone Fax CHILDREN'S INFORMATION Child's Name Date of Birth (age) School (grade) Residing with: Guardian ad Litem or Child Representative: ([ ] has been appointed for the child(ren) and shall have full access to child(ren) and all relevant documents and mediation reports.) Name Telephone Address Fax Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Fee allocation: [ ] Party A shall pay % and Party B % shall pay of mediator's fees. [ ] Party shall initially pay all fees, but the finial allocation of fees reserved. [ ] This is a low-income case and the mediator shall provide services [ ] at a reduced fee [ ] pro bono. The parties represent to the court as follows: (at least one box must be checked) [ ] No orders of protection have ever been entered involving the parties to this case, or [ ] The parties are, or have been in the past, involved in a proceeding(s) under the Illinois Domestic Violence Act. [ ] A current order of protection prohibits one of the parties from having any contact with the other party. County and Case Number(s) of IDVA cases involving the parties: If the parties in mediation are subject to an order of protection which prohibits contact, they shall attend separate orientation and mediation sessions only. Additional Orders: Unless otherwise ordered, or at the specific request of the mediator, neither party, nor counsel for either party, nor any person acting on behalf of either party, shall send pleadings, correspondence or other written materials to the appointed mediator. Prior to commencing mediation, all parties including the mediator shall sign a confidentiality agreement in conformity with Local Court Rule G-5.B.7. Except as otherwise provided by law or local court rule, all written and verbal communications made in a mediation session are confidential and may not be disclosed by the mediator or any other participant or observer of the mediation, except that parties may report to their attorneys or counselors who shall maintain confidentiality. Neither party shall discuss the details of the mediation sessions with their minor child or children. The mediator may include the minor child(ren) in the mediation process at his or her discretion. At the initial orientation session the mediator shall inform the parties of their rights and obligations in mediation. In addition, at the initial orientation session and from time to time as necessary during the course of the mediation, the mediator shall screen the parties for the presence of impairments to mediation. An impediment to mediation is defined as any condition, including but not limited to domestic violence or intimidation, substance abuse, child abuse, mental illness or a cognitive impairment, which hinders the ability of a party to negotiate safely, competently, or in good faith. If a mediator determines that an impairment exists which hinders the ability of the parties to negotiate safely, competently, or in good faith, meditation shall terminate and the case shall be returned to court for further proceedings, unless the parties agree to continue to mediate and the mediator determines that the implementation of safeguards would remove the impediment(s). The parties are expected to attempt to mediate their dispute in good faith. Failure to attend a mediation session or failure to participate in mediation in good faith may subject a party to sanctions. Sanctions may include an assessment of mediation costs and/or attorneys fees incurred by the other party. Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com Mediation shall terminate upon the following: a. When all issues have been resolved, or b. When an individual necessary to facilitate settlement of the dispute refuses to be present, or c. When in the opinion of the mediator no purpose would be served by continuing the mediation, or d. When the mediator determines that an impairment exists which hinders the ability of the parties to negotiate safely, competently, or in good faith, or e. After three hours of mediation upon the request of either party, or f. Upon order of court for good cause shown. The mediator shall prepare and file with the circuit clerk a Mediator's Status Report on the prescribed form within 10 days of the termination of mediation or within 10 days prior to the status date set on page 1 of this order. The report shall contain the following information (use the Ninth Judicial Circuit prescribed Mediator's Status Report): a. The number, duration, and attendance at mediation sessions. b. Whether mediation has been terminated. c. Whether the mediator recommends additional mediation sessions. d. Whether an agreement was reached. e. The status of payment of the fees for mediation, or if mediation services were provided pro bono or at a reduced rate. No permanent custody/visitation hearing shall be set until such time as the mediation is completed. EACH COUNSEL OR PARTY IS TO PROVIDE A COPY OF THIS ORDER TO THE MEDIATOR. Entered this day of , 20 . Judge Copy Received: Father or Father's Attorney Mother or Mother's Attorney Prepared by: Attorney's Name: Address: City: State: Zip: Phone: Fax: ARDC: Rev 4-27-07 Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com