D&F (Non-PMP) Participant Evaluation Form

Please help us evaluate how effective this mediation program is by giving us your feedback on this survey. It is completely voluntary and anonymous. Before you begin, be sure that you have your Case Number (if you do not have your Case Number, please put your initials in the Case Number field).

CRG Case #:

Date:

Date

Mediators:

I have physical custody of the child(ren) or I am the primary caretaker:

I am the:

Other

Agreement Reached?

1. How did you hear about this mediation program? Please check as many as apply.

2. Did you receive clear information about the mediation program and the mediation process

3. Would you use this program again?

4. Would you recommend this program to others?

5. What is your current personal income? (optional) Please check the most appropriate category:

6. What is your race/ethnicity? (Optional) Please check as many as apply:

7. How would you describe the level of conflict between you and the other parent during this session?

8. Why did you choose mediation? Please check as many as apply:

9. Did the mediator(s) assist you with any of the following ways? Please check the appropriate answer.

Other

10. Did mediation help you make progress in achieving any of the following? Please check the appropriate box:

Rows	Full Progress	Some Progress	No Progress	Does not apply
To produce an agreement or settlement for an uncontested divorce
Alimony (spousal support)
Division of assets / property

11. If children are involved in the situation that brought you to mediation, please indicate how much progress was made through mediation in resolving the child-related issues listed below. Check all that apply:

Rows	Full Progress	Some Progress	No Progress	Does not apply
Custody of child
Child support
Visitions
Assignment of parent responsibilities
Develop/revise a parenting plan

12. Would you use this program again?

14. Any additional thoughts about the mediation process, mediator(s) and/or for improving the program?