Screening Cases for Suitability for Mediation IN-PERSON SCREENING TOOL The following introductory information should be provided to the person being interviewed: This interview will help me determine if mediation or other forms of alternative dispute resolution will be appropriate in your case. In mediation you and the other person will be asked to meet with a neutral third party. The mediator will help you and the other person discuss and possibly reach an agreement in all or some aspect of your case. It is a voluntary process and you do not have to reach an agreement. For mediation to be successful, those participating must be “equals” who are able to talk with one another and agree or disagree without being fearful or intimidated. These questions will help me determine whether mediation may be appropriate in your case. Please answer these questions as truthfully as possible. What you say to me here is confidential and will not be disclosed to the court or your partner. The document I complete will be destroyed after our interview and will not be placed in the court record. There are some exceptions to that confidentiality. If you tell me about a child who is being abused, or about your intent to hurt someone, I may be required by law to report that information to authorities. Column A Column B YES YES 1. Are you generally unable to resolve differences with your spouse/partner in a non-violent, non-threatening way? 2. Is there anything that you feel you can’t say in front of your spouse/partner? 3. Is there anything that goes on at home that makes you feel afraid? 4. Has your spouse/partner ever physically hurt or threaten you or your child? Has he/she ever: Hit you? Pushed you? Smacked you? Kicked you? Bit you? Pinched you? Choked you? Hit you with an object other than a hand? [Check YES if any of the above are indicated] 5. Does your partner/spouse verbally abuse you? Call you names? Put you down? 6. Has your spouse/partner ever destroyed your clothing, objects, or something you especially cared about? 7. Have the police ever been called to your house to settle a dispute or because of violence? 8. Have protective services ever been involved with your children? 9. Has your spouse/partner ever forced you to have sex when you didn’t want to? Make you do sexual things you don’t want to do? 10. Has your spouse/partner ever prevented you from leaving the house, seeing friends, getting a job, or finishing school? 11. Has your partner/spouse ever used or threatened to use a weapon against you? 12. Has your spouse/partner ever hurt or threatened to hurt pets? 13. Is your spouse/partner excessively jealous? Does he/she accuse you of having affairs? Does he/she check up on what you have been doing and not believe your answers? 14. Do you or your spouse or partner abuse drugs or alcohol? What happens? 15. Do you have any concerns about your case being sent to mediation? Number of boxes checked YES in each column: If ONE or more in this column, MEDIATION is NOT APPROPRIATE If ONE or more in this column, MEDIATION is PROBABLY NOT APPROPRIATE. American LegalNet, Inc. www.USCourtForms.com CM 17 - July 2005