FORM ADR-1005 Revised November 2017 1 OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA MEDIATOR PROFILE FORM Please use black ink so this document will be legible when scanned. 1. Name: Last First Middle Business Name (if different from above): Mailing Address: Street and/or Post Office Box City State Zip Code County 2. Phones/HomeWorkFax: 3. E-Mail:Website: Please check any item you do NOT want posted in the online Searchable Mediator Directory. Business Name Street Address City County Zip Code Home Phone Work Phone Fax Email Website If you prefer to post alternate contact information online for any of the above, please list that information below. 4. Education/Licensure: BA BS CDP CFP CPA DDS DMin EdD JD LCSW LLM LMFT LPC LPN MA MBA MD MMin MPA MEd MS MSW PhD RN American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR-1005 Revised November 2017 2 5. Other Court-Related Positions: Commissioner in Chancery Guardian Ad Litem Magistrate Probation Officer Retired Judge 6. Dispute Resolution Training Hours Received: 20-39 40-59 60-99 100-199 over 200 7. Number of Mediations Conducted: less than 10 10-29 30-49 50-100 over 100 8. Numbers of Years Experience in Dispute Resolution: 0-2 3-5 6-10 over 10 9. Types of Dispute Resolution Services Provided: Arbitration Conciliation Family Group Conferencing Large Group Facilitation Mediation Neutral Case Evaluation Ombuds Partnering Youth Accountability Conferencing 10. Hours Available: 8-5 M-F Evenings Weekends By Appointment 11. Languages in Which You Are Proficient: American Sign Language Arabic Bosnian Bulgarian Cambodian Cantonese Creole Filipino French German Greek Hebrew Hindi Italian Japanese Korean Laotian Latvian Mandarin Mongolian Norwegian Persian (Farsi) Polish Portuguese Romanian Russian Spanish Thai Turkish Ukrainian Vietnamese American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR-1005 Revised November 2017 3 12. Types of Disputes in Which You Have Specialized Training and Experience: ADA Adult Guardianship Aeronautics Business/Consumer Child Abuse Neglect/Dependency Child Support Church Community Construction Contract Corporate Crisis Intervention Custody/Visitation Elder Employment Environment Federal Securities Federal Workplace Finances/Tax/Debt Collection Foreign Affairs Forensic Healthcare Historic Preservation Housing (FHA) Insurance Interstate Commerce Juvenile Justice Labor Landlord/Tenant Law Enforcement Maritime Medical Malpractice Mental Health Military Multi-cultural Multi-party Parent/Teen Peer Mediation Personal Injury Probate Property Distribution Public Policy Real Estate Restorative Justice Same-sex Relationships Special Education Spousal Support U.S. Postal Service World Bank Workers Compensation 13. Location (Judicial Circuit) Where You Wish to be Listed: Choose only 1 circuit. Leave blank if there is no circuit for which you want to be listed. (View the circuit map of Virginia ) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 American LegalNet, Inc. www.FormsWorkFlow.com FORM ADR-1005 Revised November 2017 4 14. Customary Hourly Fee: under $50 $50-74 $75-99 $100-124 $125-149 $150-199 over $200 sliding scale available travel reimbursement 15. Are you willing to make reasonable accommodations to provide services for persons with disabilities consistent with the Americans with Disabilities Act? Yes No Please Note: In the mediator database, we will also record types of certification held, mentor status, dates of certification and recertification, date next due for recertification, certification number, and MIS user name. Please see important notes on the next page. Signature of Mediator Date Please note that the information contained on your Mediator Profile Form will be entered in the mediator database maintained by the Office of the Executive Secretary and this same information will appear in the Searchable Mediator Directory located on the court website at www.vacourts.gov . Even without a profile form, the information you provide in your Application for Mediator Certification is entered in the mediator database and that same information is supplied to the Internet directory. If you do not wish to be included in the Internet directory, please notify the office of Dispute Resolution Services in writing. Without such a request, you will automatically be included in the Internet directory. If you choose not to be included in the directory, you will still receive communications from the DRS office and be counted as a court-certified mediator. From time to time, ADR organizations request the DRS office to provide contact information for our certified mediators. The organizations wish to disseminate information regarding ADR events, membership, and training and employment opportunities. If you wish to be EXCLUDED from the contact list, please let us know. Please return this form to: Dispute Resolution Services Office of the Executive Secretary Supreme Court of Virginia 100 North Ninth Street, Third Floor Richmond, Virginia 23219 Telephone: 804-786-6455 Fax: 804-786-4760 E-mail: jlamp@vacourts.gov American LegalNet, Inc. www.FormsWorkFlow.com