IN THE CIRCUIT COURT OF THE NINETEENTH JUDICIAL CIRCUIT LAKE COUNTY, ILLINOIS Petitioner, vs. Respondent. ) ) ) ) Gen No. ) ) Previous or current OPs involving either of the parties: ) OP Case No: County: ) OP Case No: County: ORDER OF REFERRAL TO MEDIATION Pursuant to Local Rule 11.13, the parties are ordered to participate in mediation. Mediator: 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 Joint custody pursuant to 750 ILCS 5/602.1 Other non-economic issues relating to the children. Specify: Economic issues involving the parties. Specify: This matter is set for Status of Mediation on at M in C- The parties are ordered to contact the mediator within two business days of this order. The parties shall participate in an orientation session which shall take place no later than 21 days from the date of this order. The parties shall return to court for the Status of Mediation on the date set forth above. Party A: Name of Party: Telephone: Address of Party: Attorney for Party: Telephone: Attorney’s address: Fax: Party B: Name of Party: ` Telephone: Address of Party: Attorney for Party: Telephone: Attorney’s address: Fax: GAL/AFC/CR Name: Telephone: Fax: Address: Fee allocation: Party A % Party B % This is a low-income case and the mediator shall provide services at a reduced fee: Hourly rate: Total fee: Page 1 of 2 171-329 (Rev. 08/08) American LegalNet, Inc. www.FormsWorkflow.com Orders of Protection 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. If the parties to mediation are subject to an order of protection which prohibits contact, they shall attend separate orientation and mediation sessions only. Notice to the Parties The parties are expected 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 attorney’s fees incurred by the other party. At the initial orientation session, the mediator shall inform the parties of their rights and obligations in mediation. 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 is not 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 that hinders the ability of the parties to negotiate safely, competently, or in good faith, or e. Upon order of court for good cause shown. Failure to appear on the date(s) scheduled and/or comply with the terms in this order may subject a party to sanctions pursuant to Supreme Court Rule 219(c), including but not limited to attorney’s fees, monetary sanctions, and/or dismissal for want of prosecution. Dated at Waukegan, Illinois, this day of , 20 ENTER: Judge Prepared by: Name: Attorney for: Address: City/State/Zip: Telephone: ARDC No: Page 2 of 2 171-329 (Rev. 08/08) American LegalNet, Inc. www.FormsWorkflow.com