NINTH JUDICIAL CIRCUIT OF ILLINOIS STATISTICAL INFORMATION SHEET FOR COURT ORDERED MEDIATION PROGRAM (Circuit Court Rule Part 6.40.H.2) To each Mediator participating in the Ninth Judicial Circuit Mediation Program: As required by Circuit Court Rule, please fill out this form upon the completion or termination of each mediation case that you conduct. This information is necessary to evaluate this mediation program. Your cooperation is greatly appreciated. Please mail or fax this completed form to: Office of the Chief Judge 130 South Lafayette, Suite 30 Macomb, Illinois 61455 Phone 309-837-9278 Fax 309-833-3547 1. COUNTY FROM WHICH CASE WAS REFERRED: Case No. ______________________ [ ] Fulton [ ] Hancock [ ] Henderson [ ] Knox [ ] McDonough [ ] Warren 2. Referral source: [ ] Court Order [ ] Attorney [ ] Self-Referred [ ] Other 3. Issue(s) 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): _________________________________________ ________________________________________________________________________________ 4. Parties involved in mediation: [ ] Father [ ] Mother [ ] Grandparents Other Relatives [ ] Other Adults 5. Did children participate in mediation sessions? [ ] Yes [ ] No How many sessions: When (i.e. first session, last session): ________________________ 6. Did the mediation result in an agreement by both parties? [ ] YES: [ ] Verbal [ ] Written [ ] Signed [ ] Unsigned [ ] NO: If no agreement was reached, was mediation terminated by: [ ] Mediator [ ] Wife [ ] Husband [ ] Both parties [ ] No Show 7. Did mediation result in the case being: [ ] Fully Settled [ ] Partially Settled [ ] Not Settled 8. Which parties negotiated in good faith: [ ] Both [ ] One [ ] None 9. Total number of sessions in mediation: Date of initial mediation session:___________________ Date of final session:_________________ 10. Total number of hours in mediation: ________________ Date of initial mediation session: Date of final session: _________________ 11. Total cost of mediation: $ [ ] Regular fee [ ] Reduced fee [ ] Pro bono Have you been paid in full as of date of this report? [ ] Yes [ ] No Dated: ________________________________________ Signature Mediator Name: ________________________________ Please print or type: Address: _______________________________________________________________________________ Phone: Form 660 Statistical Information Sheet B Mediation Fax: ________________________________ Rev. 12-09 American LegalNet, Inc. www.FormsWorkFlow.com