IN THE CIRCUIT COURT OF THE 22ND JUDICIAL CIRCUIT McHENRY COUNTY, ILLINOIS ___________________________________________ Petitioner, vs. ___________________________________________ Respondent. ) ) ) ) ) ) Case Number ______________________ MEDIATOR REPORT Mediator Name: ___________________________________Referring Judge: ___________________________________ 1. Type of case: Divorce Post-Judgment Paternity Allocation of Parental Responsibilities Other ________________________________________________________ 2. This case/relevant petition was filed on (date, if know): _______/________/_______. 3. I was: Selected by the parties. Appointed by the Court as the Mediator in this matter on _______/________/_______. 4. Mediation: A. Was not held because: An agreement was reached prior to mediation Petitioner failed to appear Respondent failed to appear An impediment/impairment was found to exist 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; the next session is scheduled on ___________________________________. D. Has been terminated. 5. Participants to the Mediation: Mother Father Mother's attorney Father's attorney Children; (Number) _________ 6. Issues Mediated/ended in: (check all that apply) Allocation of parental responsibilities Parenting time Relocation to another state Financial issues 7. Interpreter Needed: No. Yes. If yes: Requested and provided Full Agreement Guardian ad litem Step-Parent(s); (Number) _______ Partial Agreement No Agreement Requested and not provided Dated:_____________________________________ Signed: _____________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com