CRCSTL Service Report
Name
First Name
Last Name
Co-Mediator Name (If Applicable)
First Name
Last Name
Observer Name (If Applicable)
First Name
Last Name
CRCSTL Case #
Court Case # (If Applicable)
Type of Dispute:
Please Select
Landlord/Tenant
Landlord/Tenant (Non-Eviction)
Family (Custody/Divorce)
Small claims
Workplace
Roommate/Roommate
Neighbor/Neighbor
Neighborhood
Citizen/Police
Workplace Solutions
Contract
Other
Was this a joint-session mediation, shuttled mediation, or conflict coaching session?
*
Please Select
Mediation
Shuttling
Conflict Coaching
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Mediation Report
Date of Mediation
-
Month
-
Day
Year
Date
Duration of Mediation (Minutes)
Petitioner/Plaintiff/Party 1 Name
First Name
Last Name
Respondent/Defendant/Party 2 Name
First Name
Last Name
Did the parties reach a resolution?
Yes
No
Pending
Outcome of the Mediation (Check all that apply.)
Continuance (for pending litigation)
Signed Agreement or MOU
Rental Assistance Referral
Referral to Other Resources
Party-drafted Consent Judgement
Payment Plan
Reconvene
Repair
Apology
Structured Move-out
Verbal Agreement Only
Other
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Conflict Coaching Report
Date of Coaching Session
-
Month
-
Day
Year
Date
Duration of Coaching Session (Minutes)
Petitioner/Plaintiff/Party 1 Name
First Name
Last Name
Other Party Name (If Applicable)
First Name
Last Name
Briefly describe the outcome of this session.
Is the party requesting a mediation through CRCSTL?
Yes
No
Not now.
I'm not sure.
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Reflection
On a scale of 1-5, with 5 being the best, how would you say you were feeling before the mediation?
Terrible
1
2
3
4
Great
5
1 is Terrible, 5 is Great
On a scale of 1-5, with 5 being the best, how would you say you were feeling after the mediation?
Worst
1
2
3
4
Best
5
1 is Worst, 5 is Best
On a scale of 1-5, with 5 being the most, how much conflict would you say there was during this mediation/session?
No conflict
1
2
3
4
Very high conflict
5
1 is No conflict, 5 is Very high conflict
Would a party to this session say you were biased or displayed bias during this mediation?
Yes
No
I'm not sure.
If so, why?
Do you feel you could have been better prepared for this mediation?
Yes
No
I'm not sure.
How could CRCSTL have better prepared you?
In reflecting on this mediation, do you feel there are particular skills that you would like to continue to work on as a mediator?
Yes
No
If so, are there particular trainings or areas of focus that you would like to participate in with CRCSTL?
Is there anything else you would like to share with CRCSTL regarding this experience?
Submit
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