AACRC Service Request

Mediator Log

This form is for you to keep track of feedback which was exchanged between you and your co-mediator. You can use this information to track your progress
Name*

First NameLast Name
Date*

MonthDayYear
Date
Case #*
Session #*
Co- Mediator

First NameLast Name
Pre-Mediation: Areas I will be focusing on for improvement during this session...
Type 3: My (+) strong points I have about myself me:*
Type 3: My (-) opportunities for improvement, I have about myself me:*
Type 3: (+) strong points from my Co-Mediator about me:*
Type 3: (-) Areas of improvement my Co-Mediator has for me:*
Type 3: My (+) I have for my Co-Mediator:*
Type 3: (-) Areas of improvement I have for my Co-Mediator *
Specific Skills I feel I need improvement on:

Agreement WritingGiving FeedbackReceiving FeedbackPrep TimeExplain MediationProcess MappingNeutralityBody LanguageReflective ListeningIdentifying FeelingIdentifying FeelingNeutral LanguageNote-TakingComfort w/SilenceFraming TopicsListing TopicsUsing Topics ListFacilitating BrainstormFacilitating Sol. SelectionWin-Win KnittingPacingCooperation w/Co-mediatorDealing with powerLogisticsOpen-ended Q’sSpecifics in SolutionsIdentifying ValuesOther
Should be Empty:

Mediator Log