MARION COUNTY CIRCUIT COURT
Mediator Application
(Attach additional sheets or resume if necessary)
(This completed form will be on file for public inspection)
1. Name: Business Name:
2. Mailing/Office Address:
3. Phone: Fax: E-mail:
4. Application for (may choose one or both):
custody issues panel financial issues panel
Financial Mediators I certify I shall maintain at least $100,000 in malpractice
insurance or self-insurance with comparable coverage Section 2.3(7). Please provide
name of Insurance company:
________________________________________________________
5. What educational degrees have you earned? (Indicate degree, grantor and subject
areas):
Is your degree from an accredited institution? Yes No
Other:
6. What is your current occupation? How long?
7. What professional certifications do you hold?
8. Please set forth the formal training in mediation that you have received to date by listing
sources, dates and hours. (Please attach copies of your certificate(s) of completion and
training outline(s)).
9. Please describe your training on legal and financial issues in separation, divorce and
family reorganization in Oregon, including property division, asset valuation, public
benefits law, domestic relations income tax law, child and spousal support and joint and
several liability for family debt; corporate and partnership law, retirement interests,
personal bankruptcy, ethics (including unauthorized practice of law), drafting, legal process
(including disclosure problems), the needs of pro se parties review by independent counsel,
finality of a judgment, and methods to carry out the parties’ agreement. (List topics, hours
and dates and attach supporting documentation.
Number of hours accredited by the Oregon State Bar:
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10. Do you have an understanding of court-connected domestic relations programs?
Yes No How?
11. Please describe any training about the court system you have had, including the number
of hours:
12. Description of how your fees are established (the court pays a set rate pursuant to SLR
12.095 for custody/parenting time mediation):
13. Are you bilingual? Yes No
If yes, please list languages spoken:
14. Please check the boxes and fill in the blanks to describe your educational background
and experience:
Bachelors in a behavioral
science related to:
family relationships
child development
conflict resolution
with course work in a
behavioral science
Post graduate experience serving
families (list full time equivalent
experience):
social work for
years
mental health for
years
conflict resolution for
years
Masters Doctoral in:
counseling
psychiatry
psychology
social work
marriage and family therapy
mental health
In a subject relating to:
children and family dynamics
education
communication
conflict resolution
Post graduate experience serving
families (list full time equivalent
experience):
social work for
Years
mental health for
Years
conflict resolution for
years
Juris Doctor with:
Course work in
family law
CLE credits in
family law
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Additional Work Experience:
List full time equivalent experience in the following areas:
mediation: years
direct therapy or counseling with an emphasis on short-term problem solving:
years
domestic relations lawyer for years
juvenile caseload (lawyer) for years
List any other relevant education and/or experience:
15. If you do not meet the specific criteria in the OJD Court-Connected Mediator
Qualifications Rules do you have other training, experience or education that qualifies you
to mediate? Please explain:
What is your plan to meet the minimum requirements? When do you plan to actually
meet the minimum requirements?
Advertising and Soliciation
16. If I am selected to serve as a mediator who provides court-connected mediation
services, I will not directly solicit such employment from a party to litigation. Direct
solicitation does not include general advertising, so long as the advertising does not
specifically target parties to litigation, claim designations such as “certified” by Marion
County Circuit Court or identify Marion County Circuit Court. Direct solicitation of
parties does not include contact with counsel. (initials)
Mediation Experience:
Domestic relations mediation, supervised by or
co-mediated with a qualified supervisor:
Number of cases
Number of hours
Domestic Relations Custody and Parenting
Time:
Number of cases
Number of hours
Supervisor
directly observed: cases hours
Domestic Relations Financial Issues:
Number of cases
Number of hours
Supervisor
directly observed: cases hours
Mediation:
Types of disputes/cases:
Number of cases:
Number of hours:
Organization/Supervisor:
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Mediator Ethics
17. I subscribe to the following code of professional ethics, standards or principles (e.g.
OMA, OSB, ACR):
I am subject to the following disciplinary rules relevant to my memberships, licenses, or
certifications:
______________________________________________________________
I certify that I am currently in good standing with all regulatory authorities of my
profession. I hereby authorize the Courts to review any professional associations and
licensing authorities that I am associated with and particularly with regard to any
complaints that have en filed with any such agencies or organizations I am licensed with. I
am licensed with the following agencies: Oregon State Bar
Board of: Psychologists Counselors and Therapists Clinical Social Workers
Other:
I agree to keep the Marion County Circuit Court informed of any changes in my licensure
status or qualifications to be listed as a mediator.
I certify that I have read and will comply with the Oregon Revised Statutes, Supplemental
Local Rules for Marion County that pertain to civil case mediation, and the Oregon Judicial
Department (OJD) Court-Connected Mediator Qualifications Rules, and that I will include
in my opening remarks the required information listed in the Mediator Ethics Section 1.4.
In addition, I agree to comply with the continuing education requirement for court-
connected mediators, Section 2.1(3) and 3.6 and all other requirements specified in the OJD
Court Connected Qualification Rules. (initials)
By signing this mediator application, I acknowledge that the information provided may be
verified, references/programs may be contacted, and I expressly consent to the release of
information.
Date Signature
Return to:
Mediation Coordinator
Marion County Circuit Court
P.O. Box 12869
Salem, OR 97309.
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