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This is a Illinois form that can be used for Juvenile Protection within Local County, Cook.
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Print Form Clear Form Mediation/Facilitation Report STATE OF ILLINOIS COUNTY OF COOK (Rev. 10/20/09) CCJP 0003 2100 } ss: IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS DEPARTMENT OF JUVENILE JUSTICE AND CHILD PROTECTION CHILD PROTECTION DIVISION IN THE INTEREST OF _______________________________________________________ Minor(s) } No(s). ____________________________ Calendar # ________________________ MEDIATION/FACILITATION REPORT Interim Order to Mediation/Facilitation Entered on: ____________________, _________ Final Scheduled mediation/facilitation Date: ____________________, _________ The following individuals did not participate in and/or report to the scheduled mediation/facilitation: ________________ ________________________________________________________________________________________________ MEDIATION/FACILITATION OCCURRED This is the (1st 2nd 3rd 4th 5th ________) mediation/facilitation session conducted pursuant to this order. The parties have reached: 2101 2102 2103 Start time: ______________ a.m./p.m. End time: ______________ a.m./p.m. Full agreement Partial agreement No written agreement The memorandum of agreement is attached The participants agreed to return to mediation/facilitation on: ______/______/______ at ____________ a.m./p.m. MEDIATION/FACILITATION DID NOT OCCUR 2104 2105 2106 At the time the group convened it determined that session would not be beneficial. The session did not occur because the above named individual(s) failed to attend. The session did not occur for the following reason(s): _____________________________________________ ____________________________________________________________________________ An informal discussion was facilitated amongst the individuals in attendance. This session will be rescheduled. This session has been rescheduled to _______________________, _________ at ___________ a.m./p.m. This session will not be rescheduled. Next court date: _______________________, _________ at ___________ a.m./p.m. ______________________________________________ Mediator/Facilitator Signature Name: Address: __________________________________________ Mediator/Facilitator Signature Child Protection Mediation and Facilitation Program Filing date: _________________________, ________ 2245 West Ogden Avenue, 8th Floor Chicago, Illinois 60612 Phone: (312) 433-5259 Atty. Code: 40305 DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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