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:

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

YesNo
I am the:

MotherFatherOther
Agreement Reached?

Full AgreementTemporary AgreementPartial AgreementNo Agreement
1. How did you hear about this mediation program? Please check as many as apply.

Recommended by a judgeInformation shared by court personnelOrdered by a judgeReferred by family or friendRecommended by court personnelInternetOther (Please explain):
2. Did you receive clear information about the mediation program and the mediation process

YesNo
3. Would you use this program again?

YesNo
4. Would you recommend this program to others?

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

Less than $10,000$10,000 to $19,000$20,000 to $29,000$30,000 to $39,000$40,000 to $49,000$50,000 to $59,000$60,000 to $65,000$65,000 or above
6. What is your race/ethnicity? (Optional) Please check as many as apply:

American Indian or Alaska NativeAsianBlack or African AmericanWhiteHispanic, Latino or Spanish origin (any race)Native Hawaiian or Other Pacific IslanderOther
7. How would you describe the level of conflict between you and the other parent during this session?

High ConflictModerate ConflictLow ConflictNo Conflict
8. Why did you choose mediation? Please check as many as apply:

It was a better option than going to courtIt was accessibleIt was freeI have heard positive things about mediationI have previous positive experience with mediationOther
9. Did the mediator(s) assist you with any of the following ways? Please check the appropriate answer.

Listened well to my needs and concernsAllowed me to make my own decisionsWas fair and unbiasedHelped identify and clarify relevant issuesHelped write up the agreement/partial agreementHelped us generate ideas & consider optionsOther

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

	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:

	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?

YesNo
12. Would you use this program again?

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