Arkansas
Al
t
e
r
na
t
ive
Dispute Resolution
C
o
mm
issio
n
Statistical
Reporting Form for Court Ordered
M
e
d
i
a
t
io
n
Please complete this
form
f
o
r
all court ordered mediations.
If
a
r
e
f
e
rr
a
l
fails
to attend mediation,
fill
in as much
in
f
o
r
m
a
tion
as possible in order
f
o
r
the
Commission
to compile accurate
st
a
tistics.
MEDIATOR
I
N
FOR
M
A
T
I
O
N
Last First M.I. Certification Number
City State Zip Phone
FILING
I
N
FOR
M
A
T
I
O
N
County Judge Circuit # Docket # (Include subject prefix, i.e. JV, DR, PR,CV)
Plaintiff’s Name Defendants Name Date Mediation was ordered
Division (please check one):
JUVENILE
DOMESTIC RELATIONS PROBATE
C
I
V
I
L
Is this case an Arkansas Access & Visitation Mediation Program Case? YES
NO
MEDIATION
I
SSU
E
S
Case Type: Please check all that apply.
For Other
c
a
t
ego
r
ies,
please
d
esc
r
i
b
e
case
c
ha
r
a
c
t
e
r
is
t
ics.
1. Motor Vehicle Negligence
2. Other Negligence
8.
Decedent Estates
16.
Separate Maintenance
9.
Trust Administration
17.
Domestic Abuse
3.
Malpractice
10.
Guardianship
18.
Families in Need of Services
4.
Product Liability
11.
Adoption
19.
Juvenile Delinquency
5.
Contracts (Please specify
12.
Divorce
20.
Dependency Neglect
type): _______________
13.
Paternity
21.
Termination of Parental Rights
6.
Equity
14.
Custody/Visitation
22.
Extended Juvenile Jurisdiction
7.
Partnership
15.
Child Support
23.
Other: __________________
1. Did the mediation take
p
l
a
ce
?
MEDIATION
S
E
SS
I
O
N(S)
A. No, mediation never began.
B. Yes, but mediation was halted, returned to court without agreement on / / .
C. Yes, mediation was completed on / / with a full agreement.
D. Yes, mediation was completed on / / with a partial agreement.
E. No agreement reached on / / .
2. Did the judge send all issues of the case to mediation
or
limited issues of the case? All Issues Limited Issues
3.
H
ow
m
an
y
m
e
d
i
a
t
io
n
sessio
n
s
we
r
e
co
ndu
c
t
e
d?
4.
H
ow
m
an
y
TOT
A
L
h
o
u
r
s
we
r
e
s
p
e
n
t
i
n
m
e
d
i
a
t
io
n?
Please complete and return
to
:
Arkansas
Al
t
e
r
na
t
ive
Dispute Resolution
C
o
mm
issio
n
A
d
m
i
n
is
t
r
a
t
ive
Office of the
C
o
u
r
t
s
625
Marshall
S
t
r
ee
t
Little Rock, AR
72201
FAX: (501)
682-9410
Rev.
01/16