SUPREME COURT OF VIRGINIA Office of the Executive Secretary Evaluation of Mediation Session(s) and Mediator(s) This information will be used to inform the court system and the mediator(s) about your experience with mediation. With your help, we can ensure that quality mediation services continue to be available to the citizens of the Commonwealth. This information may be shared with the mediator(s). I. Session Evaluation Date: _____________ Name: ____________________________________________ Address: ________________________________________________________________ Street _________________________________________________________________________ City State Zip Phone Number: (Day) _____________________ (Evening) ______________________ 1. I am (check one): a party to the mediation an attorney representing a party not at all appropriate 2. For this case, mediation was (check one): very appropriate somewhat appropriate Comments: _____________________________________________________________________ ______________________________________________________________________ 3. Total hours spent in the mediation session(s): ________ Number of Sessions: ______ 4. The mediation process was: very helpful all of the issues somewhat helpful some of the issues yes yes not at all helpful none of the issues no no (OVER) American LegalNet, Inc. www.FormsWorkFlow.com 5. Mediation ended with an agreement on: 6. Would you use mediation again? 7. Would you recommend mediation to others? FORM ADR-1002 revised December 2011 II. Mediator Evaluation Mediator B: __________________________ Print First & Last Name Print First & Last Name Mediator A: _____________________ _____________________ Mediator's Certification Number ______________________ Mediator's Certification Number Please rate your mediator(s) on the following. Circle the appropriate number. 5 = Very Good 4 = Good 3 = Adequate 2 = Unsatisfactory 1 = Poor 0 = Does not apply The Mediator . . . 1. 2. 3. 4. 5. 6. 7. 8. 9. explained the mediation process and procedures. provided useful information. was a good listener. allowed me to talk about issues that were important to me. was respectful. helped clarify issues. encouraged us to come up with our own solutions. informed me that I could consult an attorney. was neutral. Mediator A 543210 543210 543210 543210 543210 543210 543210 Mediator B 543210 543210 543210 543210 543210 543210 543210 yes yes yes no no no doesn't apply 10. wrote our agreement clearly and accurately 11. Share any comments on the mediation process and/or the mediator(s): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Please return this Form to the Mediator or Program Director, or mail directly to: Dispute Resolution Services Office of the Executive Secretary Supreme Court of Virginia FOR MEDIATOR USE ONLY 100 North Ninth Street Court: JDR GD/SC Circuit Richmond, VA 23219 Type of Dispute: ________________________ Source of Referral: Court Coordinator Private FORM ADR-1002 revised December 2011 American LegalNet, Inc. www.FormsWorkFlow.com