Virginia > Statewide > Supreme Court > ADR
Mediator Profile Form ADR-1005 - Virginia
| Mediator Profile Form Form. This is a Virginia form and can be used in ADR Supreme Court Statewide . |
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OFFICE OF THE EXECUTIVE SECRETARY SUPREME COURT OF VIRGINIA MEDIATOR PROFILE FORM Please use black ink so this document will be legible when scanned. 1. 2. 3. Name: Agency, Organization or Practice: Primary Street Address: City: State: Extension: Zip: 4. 5. 6. 7. 8. 9. Office Telephone Number: Home Telephone Number: Fax Number: Email Address: Web Address: Education/Licensure: BA EdD MA MSW BS JD MBA PhD CDP LCSW MD RN CFP LLM MMin CPA LMFT MPA DDS LPC MEd DMin LPN MS 10. Other Court-Related Positions: Commissioner in Chancery Probation Officer Guardian Ad Litem Retired Judge Magistrate 11. Dispute Resolution Training Hours Received: 20-39 40-59 60-99 100-199 over 200 12. Number of Mediations Conducted: less than 10 10-29 30-49 1 American LegalNet, Inc. www.FormsWorkFlow.com 50-100 over 100 FORM ADR-1005 Revised December 2011 13. Numbers of Years Experience in Dispute Resolution: 0-2 3-5 6-10 over 10 14. Types of Dispute Resolution Services Provided: Arbitration Conciliation Family Group Conferencing Mediation Neutral Case Evaluation Large Group Facilitation Ombuds 15. Hours Available: 8-5 M-F 16. Evenings Partnering Youth Accountability Conferencing Weekends By Appointment Languages in Which You Are Proficient: American Sign Language Cambodian German Japanese Mongolian Portuguese Turkish Cantonese Greek Korean Norwegian Romanian Ukrainian Arabic Creole Hebrew Laotian Bosnian Filipino Hindi Latvian Italian Mandarin Polish Spanish Thai Bulgarian French Persian (Farsi) Russian Vietnamese 17. Types of Disputes in Which You Have Specialized Training and Experience: ADA Adult Guardianship Aeronautics Child Support Contract Business/Consumer Church Corporate Elder Federal Workplace Forensic Employment Child Abuse Neglect/Dependency Community Crisis Intervention Environment Construction Custody/Visitation Federal Securities Finances/Tax/Debt Collection Healthcare FORM ADR-1005 Revised December 2011 Foreign Affairs Historic Preservation Housing (FHA) 2 American LegalNet, Inc. www.FormsWorkFlow.com Insurance Landlord/Tenant Interstate Commerce Law Enforcement Mental Health Multi-party Probate Real Estate Juvenile Justice Maritime Military Labor Medical Malpractice Multi-cultural Personal Injury Public Policy Parent/Teen Property Distribution Restorative Justice Peer Mediation Same-sex Relationships U.S. Postal Service 18. Special Education World Bank Spousal Support Workers Compensation In Which Judicial Circuits Would You be Willing to Provide Mediation Services: 1 8 15 22 29 2 9 16 23 30 3 10 17 24 31 4 11 18 25 All 5 12 19 26 6 13 20 27 7 14 21 28 19. Customary Hourly Fee: under $50 $150-199 $50-74 over $200 $75-99 $100-124 $125-149 sliding scale available travel reimbursement 20. Are you willing to make reasonable accommodations to provide services for persons with disabilities consistent with the Americans with Disabilities Act? Yes No Please Note: In the mediator database, we will also record types of certification held, mentor status, dates of certification and recertification, date next due for recertification, certification number, and MIS user name. Please see important notes on the next page. Signature of Mediator FORM ADR-1005 Revised December 2011 3 Date American LegalNet, Inc. www.FormsWorkFlow.com Please note that the information contained on your Mediator Profile Form will be entered in the mediator database maintained by the Office of the Executive Secretary and this same information will appear in the Searchable Mediator Directory located on the court website at www.courts.state.va.us. Even without a profile form, the information you provide in your Application for Mediator Certification is entered in the mediator database and that same information is supplied to the Internet directory. If you do not wish to be included in the Internet directory, please notify the office of Dispute Resolution Services in writing. Without such a request, you will automatically be included in the Internet directory. If you choose not to be included in the directory, you will still receive communications from the DRS office and be counted as a court-certified mediator. From time to time, ADR organizations request the DRS office to provide contact information for our certified mediators. The organizations wish to disseminate information regarding ADR events, membership, and training and employment opportunities. If you wish to be EXCLUDED from the contact list, please let us know and we will not include you. Please return this form to: Dispute Resolution Services Office of the Executive Secretary Supreme Court of Virginia 100 North Ninth Street, Third Floor Richmond, Virginia 23219 Telephone: 804-786-6455 Fax: 804-786-4760 E-mail: mrinehults@courts.state.va.us FORM ADR-1005 Revised December 2011 4 American LegalNet, Inc. www.FormsWorkFlow.com
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