Mediator Profile Form. This is a Virginia form and can be use in Supreme Court Statewide.
Tags: Mediator Profile Form, ADR-1005, Virginia Statewide, Supreme Court
OFFICE OF THE EXECUTIVE SECRETARY MEDIATOR PROFILE FORM Please use black ink so this document will be legible when scanned. 1. Name: 2. Name of Agency, Organization or Practice: 3. Primary Street Address: City: State: Zip: Extension: 4. Office Telephone Number: 5. Home Telephone Number: 6. Fax Number: 7. Email Address: 8. Web Address:____________________________________________________________ 9. Education/Licensure: ___BA ___BS ___CDP ___EdD ___JD ___MA ___ MBA ___MD ___PhD 10. Probation Officer ___DMin ___MPA ___LPC ___LPN ___ MEd ___MS Guardian Ad Litem Magistrate Retired Judge Dispute Resolution Training Hours Received: 20-39 12. ___MMin ___LMFT ___DDS Other Court-Related Positions: Commissioner in Chancery 11. ___LLM ___CPA ___RN ___MSW ___LCSW ___CFP 40-59 60-99 100-199 over 200 Number of Mediations Conducted: less than 10 FORM ADR-1005 Revised January 2009 10-29 30-49 50-100 over 100 1 American LegalNet, Inc. www.FormsWorkflow.com 13. Numbers of Years Experience in Dispute Resolution: 0-2 14. 3-5 6-10 over 10 Types of Dispute Resolution Services Provided: Arbitration Conciliation Family Group Conferencing Large Group Facilitation Ombuds 15. Partnering Neutral Case Evaluation Youth Accountability Conferencing Hours Available: 8-5 M-F 16. Mediation Evenings Weekends By Appointment Languages in Which You Are Proficient: American Sign Language Cambodian German Japanese Arabic Cantonese Greek Bosnian Creole Hebrew Korean Filipino Hindi Laotian Norwegian Italian Portuguese Romanian Russian Mandarin Persian (Farsi) Turkish Ukrainian French Latvian Mongolian 17. Bulgarian Polish Spanish Thai Vietnamese Types of Disputes in Which You Have Specialized Training and Experience: ADA Adult Guardianship Aeronautics Business/Consumer Child Abuse Neglect/Dependency Child Support Community Contract Crisis Intervention Environment Construction Custody/Visitation Federal Securities Finances/Tax/Debt Collection Healthcare FORM ADR-1005 Revised January 2009 Corporate Elder Employment Federal Workplace Foreign Affairs Historic Preservation Church Forensic Housing (FHA) Insurance 2 American LegalNet, Inc. www.FormsWorkflow.com Interstate Commerce Juvenile Justice Landlord/Tenant Labor Law Enforcement Maritime Mental Health Military Medical Malpractice Multi-cultural Multi-party Personal Injury Probate Property Distribution Real Estate Restorative Justice Public Policy Same-sex Relationships U.S. Postal Service 18. Parent/Teen Peer Mediation Special Education World Bank Spousal Support Workers Compensation In Which Judicial Circuits Would You be Willing to Provide Mediation Services: 1 2 3 9 10 4 11 5 12 6 13 7 14 8 15 16 18 19 20 21 22 23 24 25 26 27 28 29 30 19. 17 31 ___ All Customary Hourly Fee: under $50 $50-74 $150-199 over $200 $75-99 $100-124 $125-149 sliding scale available travel reimbursement 20. 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 FORM ADR-1005 Revised January 2009 __________________________ Date 3 American LegalNet, Inc. www.FormsWorkflow.com 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.courts.state.va.us. 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 be on the mediator mailing list and be counted as a court-certified mediator. 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: firstname.lastname@example.org FORM ADR-1005 Revised January 2009 4 American LegalNet, Inc. www.FormsWorkflow.com