Parenting Plan (with Reduced Fees) : Individual Forms : Our Services : Mediation West

Parenting Plan Mediation

Open a parenting plan mediation
Before you begin. Please note that you will need the following to complete your form for mediation:
- Contact information for the other participant
- Your court case number (if filed in court)
You will also need to submit one of the following payment options:
- $479
  - This covers the cost of your mediation unless following your mediation you, the other participant, and the mediator decide together on additional sessions. Those sessions would require additional payment.
- $159
  - This covers an initial installment. The office will contact you with your generated payment schedule for two remaining installments of $160. This is generally spaced out over 4 weeks but may vary depending on how long a mediation has been active in our system.
- $39 non-refundable payment and a reduced fee application.
  - This grant-subsidized option requires income verification. This can be last year's tax return, your last two consecutive paystubs, or a letter from a government agency stating the approval amount for state benefits of some kind such as unemployment, SNAP, ADC, etc.
Have you had contact from Mediation West about an invitation to mediate?*

YesNo
If so, what file number were you given?
Name of other party or parties who invited you to mediate*

First NameLast Name
Would you like to accept the invitation to mediate?*

Yes please, I doNo thank you, I do not
How did you hear about us?*

Mediation is a voluntary process and Mediation West is one provider of this service.

You or the other party may decline the invitation to mediate through our office and may work to resolve your issues through:
- direct negotiation with the other person(s)
- a private mediator
- the self-help section on the Nebraska Supreme Court Website
- a settlement conference between attorneys
- or any other means approved by the Court
Code of Conduct Agreements

I am choosing to move forward with a voluntary case using Mediation West’s services and by doing so I acknowledge and agree to Mediation West’s Code of Conduct as stipulated in their Policy.
Behavior Agreement*

By checking this box I agree to abide by the Policy section labeled "Behavior." I understand this means I will be polite and cooperative with the other participant(s) and with Mediation West staff and mediator(s).
Lack of Mediation Progression Agreement*

By checking this box I agree to abide by the section labeled "Lack of Mediation Progression." I understand this means I will meaningfully mediate with the other party/parties.

About the Other Parent
The Other Parent's Name*

First NameLast Name
Preferred Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
I anticipate their preferred form of contact is:*
Do you think the other parent is expecting to hear from us?*

YesNoNot sure
How do you think the other parent will respond to the invitation to mediate?*

About Your Court Status
Do you and the other parent have a case filed in court?*

YesNoNot sure
In which County is your case filed?*
Have you been court ordered to participate in mediation?*

YesNoNot Sure
First two digits before the - in your case number*
This is often the last two digits of the year you filed the case, found before the dash. (If your case number was CI 11-27, you would enter 11 above.)
Last four digits following the - in your case number*
If your case doesn't show four digits please enter zeros before the digits that your case does include. (If your case number was CI 11-27, you would enter 0027 above.)
Judge*

About Your Attorney
Do you currently have an attorney in this matter?*

YesNo
Your Attorney's Name:*
Your Attorney's Firm:*

About the Other Parent's Attorney
Does the other parent currently have an attorney in this matter?*

YesNoNot Sure
Other Parent's Attorney:*
Other Parent's Attorney's Firm:*

About Mediation
By signing below, you consent to mediate with the other parent identified above according to the terms of the current Mediation West Policy. To read the full policy click here. Highlights of the policy include:
- Mediation is voluntary and agreements cannot be forced upon you. You have the option to review any agreements with an attorney before signing if you wish.
- Mediation West keeps the content of your sessions confidential but may need to report process information such as progress and scheduling.
- You agree to keep the content of the session confidential and agree to:
  - Not to record or transcribe sessions.
  - Identify anyone who could potentially overhear a session if joining by phone or video conference.
Recordings/transcriptions of sessions are not admissible in court and allowing other people to listen to sessions is strictly forbidden and may void any agreement reached.

Mediation West may share information about your mediation under certain circumstances (to read the full policy click here). If you would like us to release/receive information to/from someone, we need your authorization by checking the corresponding box below:
Release of Information
Release of Information to:*

My Attorney and his/her firm as listed aboveOther Professional(s)My New Spouse/Significant Other (not party you are mediating with)Additional Family MemberOther Support PersonNo Additional Persons
Other Professional*

First NameLast Name
My New Spouse/Significant Other*

First NameLast Name
Additional Family Member*

First NameLast Name
Other Support Person*

First NameLast Name

Child-Centered Mediation
I am interested in being contacted by Mediation West staff to learn about the potential of my child(ren) being part of the mediation process.*

YesNo

Statistical Information

As a Nebraska ODR-approved mediation center, Mediation West is subject to reporting requirements which includes the following statistical information. Your answers to these questions will assist us in completing these reports.
With which gender do you identify?*
Other - please specify*
With which ethnicity do you identify?*
Other - please specify*

Consent to Mediate Signature
Typing and writing in the boxes below shall constitute an electronic signature and, along with processing my payment, constitutes valid evidence of my consent to mediate under the policies of Mediation West.

I, {name}, understand I am solely responsible for reviewing and understanding all the terms and conditions.

I, {name}, agree the electronically stored copy of this consent is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.
I accept
First NameLast Name
Signature*

Powered by Jotform SignClear

Mediation Costs

Fees for services are due and payable before sessions can be scheduled and refunds are limited (to read the full policy click here).
Mediation West has been approved for funding through government grants to help supplement the cost of mediation for those who qualify. We are excited to be able to offer this option to our clients. To use these funds, however, we must supply the grantor with verification of income that falls within the range they specify.

The verification of income documents they allow is any one of the following options:
- The last two consecutive paystubs from your employment
- The first two pages of your last-filed income tax return
- A benefits confirmation letter specifying the amount of benefit qualified for/being received from a government agency (ie Unemployment, SNAP, ADC, etc.)
- A declaration signed by a judge granting you Informa Pauperis status
- Verification of incarceration
You may choose one of the following options in the box below:

1. Submit a $39 non-refundable payment and proceed to the application for a reduced rate.

2. Submit a $159 initial installment and you will be contacted with your schedule for the 2 remaining installments of $160.

3. Submit a $479 payment for services through your first mediation session. If you agree to additional session(s) an additional payment will be required.
Payment Options*

Reduced Rate Application
When submitting your request to mediate today, you will need to submit a $39 payment, complete the reduced fee application on the next page, and upload the required income verification. Once your application for reduced fees is processed, you will receive a link with the balance due and instructions for submitting your payment.
Number of adults in your household*
(*Note each adult listed must provide income verification in order to be counted toward the household total. If there are adults in your home who do not have appropriate income verification please exclude them from your count.)
Number of children that live in your household more than 50% of the time*
Total annual gross household income before deductions*
Which type of income verification will you be uploading?*

The last two consecutive paystubs from your employmentThe first two pages of last filed income tax returnA benefits confirmation letter specifying the amount of benefit qualified for/being received from a government agency (ie Unemployment, SNAP, ADC, etc.)A declaration signed by a judge of Informa Pauperis statusVerification of incarceration
Income verification document*

Please note you may upload multiple files to this same section, however an additional box is located below for 2 separate uploads if you prefer or run into problems with multiple file upload.
Cancelof
Paystub #1*

Please note you may upload multiple files to this same section, however an additional box is located below for 2 separate uploads if you prefer or run into problems with multiple file upload.
Cancelof
Paystub #2*

Cancelof

I have reviewed all of my answers and am ready to submit my form*

Yes
Processing Fee
Cover the fee associated with this online transaction?

Yes, I will donate to cover the cost of this transaction
Amount Due Today*
Payment Amount*

prevnext( X )
USDDescription

Payment Methods

Debit or Credit Card

Please click one of the PayPal options to complete payment and submit the form.

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Parenting Plan Mediation

Before you begin. Please note that you will need the following to complete your form for mediation:

About You

About the Other Parent

About Your Court Status

About Your Attorney

About the Other Parent's Attorney

About the Relationship

Release of Information

Child-Centered Mediation

Statistical Information

Consent to Mediate Signature

Reduced Rate Application