Fillable Petitioner, and Respondent. ORDER FOR DOMESTIC MEDIATION (Kansas Judicial Branch)

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Petitioner, and Respondent. ORDER FOR DOMESTIC MEDIATION (Kansas Judicial Branch)

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IN THE DISTRICT COURT OF __________ COUNTY, KANSAS
In the Matter of:
Case No. _____________
Division No. __________
__________________________
Petitioner,
and
___________________________
Respondent.
ORDER FOR DOMESTIC MEDIATION
The Court finds that domestic mediation is appropriate for this case. Domestic mediation
is a confidential process in which a third party--who has no decision-making authority and is
impartial to the issues being discussed--assists the parties in defining the issues in dispute,
facilitates communication between the parties, and assists the parties in reaching a resolution.
The best interests of the parties and their minor child(ren) are served by an amicable settlement
of the custody, residency and parenting time issues.
The Court therefore orders;
1) The parties will participate in domestic mediation.
2) The Court appoints the following as domestic mediator:
Name: __________________________________
Address: ________________________________
Phone: __________________________________
Email: __________________________________
The domestic mediator serves and functions under the direction and control of the Court,
and has qualified quasi-judicial immunity. If the domestic mediator is also a licensed
attorney, he or she is not representing either party or offering legal advice to the parties.
3) The domestic mediator will meet with the parties to assist them in reaching
agreements. The parties will meet with the domestic mediator at such times, places and
appointments which are set and will promptly provide such information as the domestic mediator
requests.
4) The issues to be mediated are:
☐ Residential Placement (“home base”, school attendance, main address)
☐ Parenting Time/Schedule
☐ Legal Custody/Decision Making
☐ Other Co-parenting Issues that may arise during the domestic mediation
process, to be considered at the discretion of the domestic mediator; and
☐ Other: ______________________________________________________
_________________________________________________________________.
5) The fee for the domestic mediation will be ___________________.
6) Mediation is a confidential process, subject to the exclusions described in K.S.A.
5-512(b) and K.S.A. 23-3505(b).
7) The domestic mediator is a mandated reporter for child abuse pursuant to KSA
38-2223(a)(1)(D).
8) The domestic mediator must screen and continually monitor each dispute for
domestic violence.
9) Failure to participate in domestic mediation may be considered contempt of court.
IT IS SO ORDERED.
___________________________________
JUDGE
Counsel for Petitioner: __________________________________________________________
Petitioner: ____________________________________________________________________
Petitioner’s Address: ____________________________________________________________
Petitioner’s Phone #s: Work _____________Home _______________Cell_________________
Petitioner’s E-mail Address: _____________________________________________________
Counsel for Respondent: _________________________________________________________
Respondent: ___________________________________________________________________
Respondent’s Address: ___________________________
________________________________
Respondent’s Phone #s: Work _____________Home ______________Cell_________________
Respondent’s E-Mail Address: ____________________________________________________
Counsel for Third Party: _________________________________________________________
Third Party: ___________________________________________________________________
Third Party’s Address: ___________________________________________________________
Third Party’s Phone #s: Work _____________Home ______________Cell_________________
Third Party’s E-Mail Address: ____________________________________________________
Guardian ad Litem/Other: ________________________________________________________
GAL/Other’s Address: ___________________________________________________________
GAL/Other’s Phone #s: Work ___________Home _____________Cell____________________
GAL/Other’s E-Mail Address: _____________________________________________________
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Petitioner, and Respondent. ORDER FOR DOMESTIC MEDIATION (Kansas Judicial Branch)

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Completed 20 March 2021

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