17th CIRCUIT DIVORCE MEDIATION PROGRAM STATISTICAL TERMINATION RECORD Please complete this form following the termination of each mediation case that you conduct. This information will be used to help evaluate the program. ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ ¡ 1] 2] 3] 4] Winnebago County Case Attorney Boone County Case ¡ ¡ ¡ How many ¡ When (i.e. first session, last session) ¡ 6] Length of time couple was mediation When did mediation begin: separated or divorced 7] prior to judgment of dissolution hearing after final initial court settlement: post decree ¡ b] What other issues surfaced during mediation which were not resolved? 9] 10] If no agreement was reached, was mediation terminated by: Mediator Couple Wife Husband All agreed to terminate No Show Total number of sessions in mediation Total number of hours in mediation Time span required in mediation process: Date of initial mediation session Total cost of mediation: ¡ ¡ ¡ ¡ ¡ ¡ 11] 12] 13] Date of termination session 14] 15] Which parties negotiated in good faith? Both One APPENDIX CC 2002 © American LegalNet, Inc. ¡ Did mediation result in an agreement by both parties? Yes Written or Verbal Signed or ¡ ¡ ¡ 8] Original issues presented for mediation: Custody a] What other issues were resolved? ¡ 5] Did children participate in mediation sessions? Yes Visitation ¡ ¡ Parties involved in mediation: Other Relatives ¡ Mother Father Other Adults Grandparents Unsigned None ¡ Was mediation required by a joint parenting agreement? Referral source: Court Order Self-Referred Yes Other No No prior to the beginning of Both Other