Michigan > Statewide > Civil > General
Domestic Relations Mediator Application MC 281b - Michigan
| Domestic Relations Mediator Application Form. This is a Michigan form and can be used in General Civil 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 Procedures pursuant to MCR 3.216(G)(2). Service as a case evaluator under MCR 2.403 does not constitute a qualification 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 is available to the public for inspection. Please type or print neatly. 1. Full name (first, middle initial, last) 3. Address where you can be contacted 4. Telephone no. 5. Fax no. 6. E-mail address 2. Bar no. if applicable P Part A: Domestic Relations Mediator Qualifications Complete items 7 and 8, and either item 9, 10, or 11 as appropriate. 7. 8. 9. Is this a new application? renewal? If renewing, complete item 11 and attach a copy of your original application. Date Completed a 4-hour domestic violence program approved by the SCAO on . Qualification through State Court Administrative Office (SCAO) Approved Training / Association for Conflict Resolution (ACR) Training a. SCAO/ACR approved training completed on Trainer: If the ACR training was completed more than 2 years before applying, the applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. Date . (attach copy of certificate) b. Licensed in appropriate field. Specify Attach copy of diploma. Master or graduate degree in appropriate field. 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 include party names. d. Conducted 1 domestic relations mediation to conclusion. Do not provide party names. Specify date and name of mediator serving as supervisor and attach verification. MC 281b (3/06) continued on page 2 DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 1 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkflow.com Domestic 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. Complete on separate page if needed. Do not provide party names. Detail below. f. As a non-Michigan licensed lawyer/nonlawyer, completed on Date , a 6-hour program addressing basic Michigan laws, rules, and guidelines governing domestic relations actions. Instructor: 10. Qualification by Training and Experience Comparable to ACR Approved Training 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 information gathering skills and knowledge communication skills and knowledge professional skills and knowledge family law and family economics relationship skills and knowledge problem-solving 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 before applying, applicant must have completed at least 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. b. Licensed in appropriate field. Specify Attach copy of diploma. Master or graduate degree in appropriate field. 5 years experience in family counseling. Detail below. Complete on separate page if needed. continued on page 3 MC 281b (3/06) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 2 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkflow.com Domestic Relations Mediator Application, continued from page 2 Part A: Domestic Relations Mediator Qualifications (continued) 10. c. Mediated or comediated at least 40 hours or 10 domestic relations cases in the two years prior to this application. Complete on separate page if needed. Do not provide party names. Detail below. d. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Complete on separate page if needed. Do not provide party names. Detail below. e. As a non-Michigan licensed lawyer/nonlawyer, completed on Date , a 6-hour program addressing basic Michigan laws, rules, and guidelines governing domestic relations actions. Instructor: 11. Renewing Application If the mediation training was completed more than 2 years before applying, applicant must have completed 8 hours of advanced mediation training in the 2 years before applying. Specify type of training, dates, and trainers, and attach copy of certificate. CERTIFICATION I certify that I: a) meet the requirements for service under the court's mediator selection plan; b) will not discriminate against parties or attorneys on the basis of race, ethnic origin, gender, or other protected personal characteristic; and c) will comply with the court's ADR plan, orders of the court regarding cases submitted to mediation, and the standards of conduct adopted by the State Court Administrator. My hourly fee is $ . Date Signature MC 281b (3/06) DOMESTIC RELATIONS MEDIATOR APPLICATION, Page 3 of 4 MCR 3.216(G) American LegalNet, Inc. www.FormsWorkflow.com Domestic 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 accordance with MCR 3.216(F)(1)(c) and will be maintained separately from your application. Check the boxes that apply to you. Gender: Female Race/Ethnicity: American Indian or Alaskan Native Asian or Pacific Islander Black/African American (non-Hispanic) Hispanic White/Caucasian (non-Hispanic) Other (specify): Male Part C: Pro Bono and Observee/Observer Information Providing the
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