Michigan > Statewide > Alternative Dispute Resolution
Domestic Relations Mediator Application MC 281b - Michigan
| Domestic Relations Mediator Application Form. This is a Michigan form and can be used in Alternative Dispute Resolution Statewide . |
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Approved, SCAO DOMESTIC RELATIONS MEDIATOR APPLICATION To be eligible to serve as a domestic relations mediator, you must meet the training and experience criteria specified either in MCR 3.216(G) or in the SCAO Mediation Training Standards and Proced ures pursuant to MCR 3.216(G)(2). Service as a case evaluator under MCR 2.403 does not constitute a qualif ication for serving as a mediator. Refer to the Mediation Training Standards and Procedures for further information about minimum qualifications. Note: Except for Part B, the information provided in this application i s available to the public for inspection. Please type or print neatly. 1. Full name (first, middle initial, last) 2. Bar no. if applicable P 3. Address where you can be contacted 4. Telephone no. 5. Fax no. 6. E-mail address ( ) ( ) Part A: Domestic Relations Mediator Qualifications Complete items 7 and 8, and either item 9, 10, or 11 as appropriate)7. Is this a new application? renewal? If renewing, complete item 11 and attach a copy of your origin al application.8. Completed a 4-hour domestic violence program approved by the SCAO on . Date 9. Qualification through State Court Administrative Office (SCAO) Approve d Training / Association for Conflict Resolution (ACR) Training a. SCAO/ACR Approved training completed on . (attach copy of certificate) Date Trainer: If the ACR training was completed more than 2 years prior to the applica tion, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates, and trainers, and attach copy of cert ificate. b. Licensed in appropriate field. Specify Master or graduate degree in appropriate field. Attach copy of diploma. 5 years experience in family counseling. Detail below. Complete on separate page if needed. c. Observed 2 domestic relations mediation proceedings. Specify dates and mediator names and attach verification. Do not includ e party names. d. Conducted 1 domestic relations mediation to conclusion. Specify date and name of mediator serving as supervisor and attach veri fication. Do not provide party names. continued on page 2 MC 281b (4/05) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 1 of 4 MCR 3.216(G) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Domestic Relations Mediator Application, continued from page 1 Part A: Domestic Relations Mediator Qualifications (continued) 9. e. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. f. As a non-Michigan licensed lawyer/non-lawyer, completed on , Date a 6-hour program addressing basic Michigan laws, rules, and guidelines g overning domestic relations actions. Instructor: 10. Qualification by Training and Experience Comparable to ACR Approved Trai ning a. Completed a training course of at least 24 hours including participation in mediation and at least 25% role play by December 31, 2000. Attached are: 1) a certificate of completed training; 2) a copy of the training agenda; 3) the name of the trainer; 4) the date of the training; and 5) the dates of attendance. Training included the following core elements: Check appropriate boxes experience of divorce for adults and children family law and family economics information gathering skills and knowledge relationship skills and knowledge communication skills and knowledge problem-solving skills and knowledge professional skills and knowledge mediation, negotiation, and conflict management theory and skills ethical decision-making and values skills and knowledge If the training was completed more than 2 years prior to this applicatio n, completed at least 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates, and trainers, and attach copy of certif icate. b. Licensed in appropriate field. Specify Master or graduate degree in appropriate field. Attach copy of diploma. 5 years experience in family counseling. Detail below. Complete on separate page if needed. continued on page 3 MC 281b (4/05) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 2 of 4 MCR 3.216(G) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Domestic Relations Mediator Application, continued from page 2 Part A: Domestic Relations Mediator Qualifications (continued) 10. c. Mediated or co-mediated at least 40 hours or 10 domestic relations cases in the two years prior to this application. Detail below. Complete on separate page if needed. Do not provide party names. d. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Detail below. Complete on separate page if needed. Do not provide party names. e. As a non-Michigan licensed lawyer/non-lawyer, completed on , Date a 6-hour program addressing basic Michigan laws, rules, and guidelines g overning domestic relations actions. Instructor: 11. Renewing Application If the mediation training was completed more than 2 years prior to the a pplication, completed 8 hours of advanced mediation training in the 2 years prior to this application. Specify type of training, dates, and trainers, and attach copy of cert ificate. CERTIFICATION I certify that I: a) meet the requirements for service under the court s mediator selection plan; b) will not discriminate against partiesor attorneys on the basis of race, ethnic origin, gender, or other prote cted personal characteristic; and c) will comply with the courtsADR plan, orders of the court regarding cases submitted to mediation, an d the standards of conduct adopted by the State Court Administrator. My hourly fee is $ . Date Signature American LegalNet, Inc. www.USCourtForms.comMC 281b (4/05) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 3 of 4 MCR 3.216(G)<<<<<<<<<********>>>>>>>>>>>>> 4Domestic Relations Mediator Application - gender and race information to be maintained separately from pages 1 - 3 of application Full name (first, middle initial, last) (print or type) Bar no. (if applicable) P Part B: Gender and Race Information Providing the following information is optional. It is requested in acc ordance with MCR 3.216(F)(1)(c) will be maintained separatelyfrom your application. Check the boxes that apply to you. Gender: Female Male Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic Whit
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