West Virginia > Statewide > Family Court > Guardian Ad Litem
Application For Placement On Mediator List For Referrals From Family Court SCA-F-305 - West Virginia
| Application For Placement On Mediator List For Referrals From Family Court Form. This is a West Virginia form and can be used in Guardian Ad Litem Family Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
APPLICATION FOR PLACEMENT ON MEDIATOR LIST FOR REFERRALS FROM FAMILY COURT To be placed on a Family Court Circuit Mediation List, the applicant must meet all requirements established by the West Virginia Supreme Court. To apply for placement, applicants must complete and verifythis form and submit all required documentation to the Administrative Office of the West Virginia Supreme Courtby mailing the form and documentation to Family Court Administrative Assistant, Room E-100, State Capitol Building, Charleston, WV 25305 and to the Family Law Master in the Family Court Circuit(s) in which the mediator would like to work. General information Please print or type the following information: Name: Address: Daytime phone number: Fax number: E-mail address: Date form completed: College or University Education I have been awarded the following degree(s) from an accredited four-year institution: A. Check all applicable: Member of WV State Bar WV licensed social worker WV licensed psychologist WV licensed counsel or Other WV professional licensure, please provide details . B. Date of licensure . If you have not checked any of the above in A of this section regarding licensure, then you must complete the following. College or university: Degree awarded: Major emphasis of study: Year degree awarded: College or university: Degree awarded: Major emphasis of study: Year degree awarded: SCA-F-305 (Rev. 08/00) Application for Placement on Mediator List Page 1 of 4 for Referral from Family Court <<<<<<<<<********>>>>>>>>>>>>> 2Please attach a copy of your diploma(s) or official transcript. Specific Family and Family Law Mediation Training I have completed a forty-hour domestic relations course approved by the West Virginia Supreme Court for mediation training. G Yes G No I completed this forty-hour training on the following date: The course of training was conducted by: in this city and state: Areyou currently a member of a professional mediation organization, if yes please name: ____________________________________________________________________________ Please attach a copy of your certificate for completion of this course of training. If you have not completed a forty-hour domestic relations course approved by the West Virginia Supreme Court for mediation training, the Court will consider for this purpose other training if you have been certifiedas a family mediator in another state: (1) Attach to this application all documents and certifications verifying your training and status; (2) List the number of family mediations that you have conducted; (3) List the names of jurisdictions and contact persons in those jurisdictions who can verify your status; (4) List the dates during which you conducted family mediations in those jurisdictions; (5) List the dates, trainers, locations and descriptions of training you have received in West Virginia family law; (6) List the dates, trainers, locations and descriptions of training you have received regarding the dynamics and other significant issues of domestic/family violence; and (7) List the dates, trainers, locations and descriptions of training you have received regarding issues effecting the balance of power between parties in mediation. Observations of Family Court Mediations I have completed two observations of family court mediations by experienced family court mediators. G Yes G No Observation No. 1: Mediator: Date: Location: Observation No. 2: Mediator: Date: Location: Co-mediations with Experienced Mediators I have completed three co-mediations with experienced family court mediators. G Yes G No Co-mediation No. 1: Mediator: Date: Location: Co-mediation No. 2: Mediator: Date: Location: SCA-F-305 (Rev. 08/00) Application for Placement on Mediator List Page 2 of 4 for Referral from Family Court <<<<<<<<<********>>>>>>>>>>>>> 3Co-mediation No. 3: Mediator: Date: Location: Professional Liability Insurance. I have professional mediation malpractice liability insurance coverage. G Yes G No Insurance company: Policy Number: Time period covered by the policy: Type of coverage: Minimum coverage: $500,000/$500,000. Continuing Education in Family Court Mediation I agree to present every two years to the Administrative Office of the West Virginia Supreme Court verification that I have completed continuing education including the following as required by Family Courtprocedure: A minimum of twelve hours of family court mediator continuing education including: (1) eight hours of instruction in family court mediation; (2) two hours of skill development, demonstration, observation and evaluation; and (3) two hours of instruction and skill development in family court mediation ethics. Required Information If you answer yes to any of the following, please include applicable dates and jurisdictions, in addition toproviding a factual explanation. I have been convicted of a felony, a violent misdemeanor, or a domestic battery or assault. G Yes G No Have you ever had your licence to practice law suspended or revoked. G Yes G No I have had a family violence, domestic violence or child abuse or neglect case or petition filed against me. G Yes G No If yes, please state how many. I have had a family violence or domestic violence order filed against me. G Yes G No If yes, please state how many. Other Requirements I agree to abide by the standards of practice established for family court mediation by the West Virginia Supreme Court of Appeals. G Yes G No There are facts about which I have knowledge that adversely bear upon my veracity, my qualifications, my ability and/or my fitness to properly, safely, and fairly mediate disputes. G Yes G No SCA-F-305 (Rev. 08/00) Application for Placement on Mediator List Page 3 of 4 for Referral from Family Court <<<<<<<<<********>>>>>>>>>>>>> 4If the response to the above listed statement was Yes, I list those facts here: .I have never had my ability, privilege, license or right to mediate disputes revoked or canceled in any jurisdiction. G Yes G No I have mediated disputes and/or have applied for the right, privilege or license to mediate disputes in thefollowing jurisdictions: .Agreement to Render a Proportional Number of Pro Bono Mediation Hours Please answer the following question, but an agreement to do pro bono mediation is not a mandatory requirement to be placed on the list. I agree to accept and mediate a number of cases referred by the West Virginia Family Court for no charge at a rate proportional to the percentage of p
|
|||||||
