OAKLAND COUNTY CIRCUIT COURT DOMESTIC RELATIONS MEDIATOR APPLICATION For further information, including information about minimum qualifications promulgated by the State Court Administrative Office, please refer to the Mediation Training Standards and Procedures provided by SCAO, the SCAO Administrative Memorandum 200101 and MCR 3.216. Service as a case evaluator under MCR 2.403 does not constitute a qualification for serving as a mediator. Please type or print neatly. 1. Full name (first, middle initial, last) 2. Bar no. (if applicable) P 3. Address where you can be contacted 4. ( ) Telephone no. 5. ( Fax no. ) 6. E-mail address Part A: Domestic Relations Mediator Qualifications (Complete either items 7 and 8, and either item 9, 10 or 11 as appropriate) Where indicated you must provide the written evidence requested. 7. Is this a 8. Completed a 4-hour domestic violence program approved by the SCAO on ______________________________. 9. Qualification through State Court Administrative Office (SCAO) Approved Training/Association for Conflict Resolution (ACR) Training new application? renewal? Date To be eligible to serve as a domestic relations mediator, you must meet the following minimum qualifications: • You must have completed a domestic relations training program approved by the State Court Administrator. • You must have one or more of the following: a) be a licensed attorney, a licensed psychologist, a licensed professional counselor, or a licensed marriage and family therapist; b) have a masters degree in counseling, social work, or marriage and family therapy; c) have a graduate degree in a behavioral science; or d) have 5 years experience in family counseling. • You must have observed two domestic relations mediation proceedings conducted by an approved mediator, and have conducted one domestic relations mediation to conclusion under the supervision and observation of an approved mediator. a. SCAO/ACR Approved training completed on _______________________________. Please attach a certificate of completed Date training. Trainer: _________________________________________________________________________________________________ If the ACR training was co0pleted more than 2 years prior to the application, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers. Attach a copy of certificate of completed training _____________________________________________________________________________________________________________________ b. Licensed in appropriate field. Specify _______________________________________________________________or Master or graduate degree in appropriate field. Specify ________________________________Attach copy of diploma or Five years experience in family counseling. Detail below. Complete on separate page if needed. _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ CE 2 (1205) MCR 3.216(G) 1 American LegalNet, Inc. www.FormsWorkflow.com Part B: Domestic Relations Mediator Qualifications (continued) 9. c. Observed or co-mediated two domestic relations mediation proceedings. Specify dates and name of qualified* mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ d. Conducted under supervision or co-mediated one domestic relations mediation to conclusion. Specify date and name of qualified* mediator who observed or co-mediated. Co-mediation can be documented as either experience or observation – do not count the same case twice. Date Name of Qualified Mediator ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ e. Requesting waiver of degree requirements, completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ f. As a non-Michigan licensed lawyer/non-lawyer, completed on __________________________ a 6-hour program addressing basic Michigan laws, rules and guidelines governing domestic relations actions. Attach certificate of completion. Instructor: ____________________________________________________________________________________________________________ 10. Qualification by Training and Experience comparable to Association for Conflict Resolution (ACR) approved training a. Completed a training course of at least 24 hours including participation in mediation and at least 25% role play by December 31, 2000. Please attach: 1) a certificate of completed training; 2) a copy of the training agenda; 3) the name of the trainer: 4) the date of the training; and 5) the dates of attendance. Training included the following core elements: Check appropriate boxes experience of divorce for adults and children family law and family economics information gathering skills and knowledge relationship skills and knowledge communication skills and knowledge problem-solving skills and knowledge professional skills and knowledge mediation, negotiation and conflict management theory and skills ethical decision-making and values skills and knowledge If the training was completed more than 2 years prior to this application, completed at least 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers. Attach copy of certificate __________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com b. Licensed in appropriate field. Specify _________________________________________________________________ or Master or graduate degree in appropriate field. Specify ____________________________________ Attach copy of diploma or Five years experience in family counseling. Detail below ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ c. Mediated or co-mediates at least 40 hours or 10 domestic relations cases in the two years prior to this application. Detail below. Complete on separate page if needed. Do not provide party names. ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ d. Requesting waiver of degree requirements, completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ e. As a non-Michigan lawyer/non-lawyer, completed on __________________________ a 6-hour program addressing basic Michigan laws, rules and guidelines governing domestic relations actions. Attach certificate of completion. Instructor: ____________________________________________________________________________________________________________ *Please see list of qualified mediators at the Oakland County ADR Office 11. Renewing Application If the mediation training was completed more than 2 years prior to the application, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates and trainers. Attach copy of certificate. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ CERTIFICATION I certify that I: a) meet the requirements for service under the Court’s mediator selection plan; b) will not discriminate against parties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and c) will comply with the Court’s ADR plan, orders of the Court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court Administrative Office. My fee for services is: ________________________ per: ____________________ My practice specialty is: _____________________________________________________ ___________________________________ Date ________________________________________________________________________ Signature Please send this completed application to: Oakland County Case Management – ADR Office 1200 N Telegraph Rd Dept 404 Pontiac MI 48341-0404 3 American LegalNet, Inc. www.FormsWorkflow.com Domestic Relations Application – pro bono and observer/observee information will not affect the status of your application to be a mediator. Part C: Pro Bono and Observee/Observer Information Providing the following information is optional. Full name (first, middle initial, last) (print or type) 1. Bar no. (if applicable) P Once you have been fully qualified to be a mediator, and have completed 40 hours of experience or 10 cases in domestic relations: A. Are you willing to be observed by a potential mediator: without pay under terms and conditions you agree upon with the potential mediator B. Are you willing to observe a potential mediator: without pay under terms and conditions you agree upon with the potential mediator 2. Would you be willing to accept a pro bono or reduced fee appointment from the court to serve as a mediator once a year? Yes ________ No _______ ___________________________________ Date ________________________________________________________________________ Signature 4 American LegalNet, Inc. www.FormsWorkflow.com Domestic Relations Application – gender and race information to be maintained separately form pages 1, 2, 3 and 4 of application Part D: Gender and Race Information Providing the following information is optional. It is requested in accordance with MCR 3.216(F)(1)(c) and will be maintained separately from your application. Full name (first, middle initial, last) (print or type) Bar no. (if applicable) P Check the boxes that apply to you. Gender: Female Male Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): ____________________________________________ 5 American LegalNet, Inc. www.FormsWorkflow.com