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Mediation Follow-up Form
This is a form for mediators to fill out after they have completed a session. This is meant to be a summary of how the mediation went for the center staff. Case Manager Emails are as follows: Leticia@aacrc.info, Noah@aacrc.info, Korli@aacrc.info
Date/Time of Mediation
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Mediator 1/Coach
*
First Name
Last Name
Mediator 2
First Name
Last Name
Observer 1
First Name
Last Name
Observer 2
First Name
Last Name
Observers
Case Manager
*
Please Select
Noah Wright
Korli Bridges
Cynthia Williams
Leticia Smith
Case Managers Email
*
example@example.com
What kind of case was this?
*
Please Select
Marital Separation
Parenting Plan (Vol)
Circuit Court
District Court
Orphans Court
Community
Police
Conflict Coaching
What style of mediation was used:
Please Select
Inclusive
Facilitative
Mediation Location?
*
In-person
Virtual
Hybrid
Case Name (Last Name/Last Name)
*
Case #
*
Session #
*
Outcome of the Session
*
Total time spent in Mediation
Prep Time
Feedback Time:
Back
Next
Next Steps
Was Another Session Scheduled?
*
Yes
No
When is the next Session?
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
If not, why?
*
Was an Agreement Reached? (Conf. Coach - Stage 4 = Yes, if not stage 4, no)
*
Yes
No
What Type of Agreement?
Draft Partial
Draft Full
Signed Full
Signed Partial
When was a written agreement promised to them by?
Who is in charge of writing up the agreement?
File Upload (upload your notes here from the session if you have not done so to the sharepoint)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Should be Empty: