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Domestic Relations Mediation Initiation Form - Georgia
| Domestic Relations Mediation Initiation Form Form. This is a Georgia form and can be used in Family Division Superior Court Fulton Local County . |
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Fulton County Office of Alternative Dispute Resolution 160 Pryor Street, Suite JG26 Atlanta, Georgia 30303 Office: 404-612-4549 Fax: 404-335-2518 DOMESTIC RELATIONS MEDIATION INITIATION FORM This form is for the initiation of domestic relations mediation through the Fulton County Office of Alternative Dispute Resolution. If mediation has not been ordered by the court, both parties need to be in agreement to mediate before submitting this form. Petitioner is to forward this completed form to the Fulton County Office of Alternative Dispute Resolution via mail or fax. The case must be an active case in Fulton County. Please direct inquiries to Lisa Jackson, ADR Court Support Specialist or Jerry Wood, ADR Program Director. COST: For Domestic Relations cases, parties are offered one 4-hour mediation session at a cost of $75 per party through the Office of Alternative Dispute Resolution. Payment must be received in the ADR Office at least 10 days prior to any scheduled mediation by certified check, money order, or other certified funds. If more than four hours are needed and the parties agree to continue, the parties will be responsible for splitting the cost at the completion of the session at the Mediator's rate. SECTION A: Date: Assigned Judge: Civil Action File No: Mediation was court ordered on _____/_____/_____. Mediation has NOT been court ordered. However, both parties agree to initiate mediation. MEDIATION SHALL BE HELD NO LATER THAN _____/_____/_____. SECTION B: PETITIONER'S INFORMATION Name: Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: Name: RESPONDENT'S INFORMATION Mailing Address: City, State, Zip: Home Phone: Work Phone: Cell Phone: SECTION C: Representing Attorney Not Applicable not represented by Attorney Name: Firm: Mailing Address: City, State, Zip: Phone: Fax: Name: Firm: Representing Attorney Not Applicable not represented by Attorney Mailing Address: City, State, Zip: Phone: Fax: 1 American LegalNet, Inc. www.FormsWorkFlow.com SECTION D: Key issues to be resolved in mediation: check all that apply Division of Property Debts, household items, vehicles, real estate property, investments, retirement, checking and savings accounts Parenting Plan Custody, visitation, major decision making concerning children, holidays and vacation planning Support Child Support, alimony, medical Insurance, life insurance, educational expenses Other (please specify) SECTION E: If Guardian ad litem has been appointed, please complete this section Name of Guardian ad Litem: Mailing Address: City, State, Zip: Phone: Fax: SECTION F: SCHEDULING Please list at least five possible dates all parties are available to mediate: Please list any special accommodations needed for the purpose of the mediation session: CONFIDENTIAL SCREENING The Office of Alternative Dispute Resolution Program is required by the Georgia Commission on Dispute Resolution to screen all domestic relations cases. Your response is confidential and is not subject to discovery. Complete and honest answers are important for the safety of the mediation as well as for resolving your dispute as quickly and efficiently as possible. To the best of your knowledge, is/are there any: (1) Incapacitating intimidation of either party by the other? (2) Concerns about physical harm to either party? (3) Criminal case(s) pending against either party? Yes Yes Yes No No No Maybe Maybe Maybe (4) List any type of abuse (spousal, child, substance, etc.), if any, that is alleged or otherwise indicated. Person Completing Form: Signature: _________________________________________________ You may fax this form to the Office of Alternative Dispute Resolution at 404-335-2518. Thank you. 2 American LegalNet, Inc. www.FormsWorkFlow.com
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