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

2. Bar no. if applicable
P

4. Telephone no.
(       )

5. Fax no.
(       )

6. E-mail address

Part A: Domestic Relations Mediator Qualifications Complete items 7,8, and 9 as appropriate.

7. Is this a 

 

 new application? 

 

 renewal? 

  Contact the local court for renewal requirements before submitting this application.

 a. Completed a 4-hour domestic violence training program approved by the State Court Administrative Office on or before

        December 31, 2012. The program was completed on 

 b. Completed an 8-hour domestic violence training program approved by the State Court Administrative Office after

        December 31, 2012. The program was completed on 

9. Qualification through State Court Administrative Office (SCAO)-Approved Training or Association for Conflict  
  Resolution (ACR)-Approved Training.

Date

Date

 .

 .

  a. At least 40 hours of SCAO or ACR-approved training completed on 

 . Attach copy of certificate and training agenda.

Date

    If either 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.

  b. 

 Licensed in appropriate field. Specify. 
 

   

 Master or graduate degree in appropriate field. Attach copy of diploma.

   

 5-years’ experience in family counseling. Detail below. Complete on separate page if needed.

    Trainer: 

 

8. 
 

 
 

 

 
 

 

 

 

 

 

 

   

 

       

       

       

 

 

 

continued on page 2

MC 281b 

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MCR 3.216(G)Domestic Relations Mediator Application, continued from page 1

Part A: Domestic Relations Mediator Qualifications (continued)

9. c.  Observed two domestic relations mediation proceedings. Specify dates and mediator names and attach verification. Do not provide party 
 

    names.

 d. Conducted one domestic relations mediation to conclusion. Specify date and name of mediator serving as supervisor and attach 

        verification. Do not provide party names.
       

 e. Requesting waiver of degree requirements: Completed 80 hours or 20 cases in domestic relations mediation. Detail 

        below. Complete on separate page if needed. Do not provide party names.

 

 

 
 
 

 
 

 

 

 

   

   

 

 

 

  

  

 

       

       

       

 

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 

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MCR 3.216(G)Domestic Relations Mediator Application - gender and race information to be maintained separately from pages 1 and 2 of 
application

Bar no. (if applicable)
P

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.

Full name (first, middle initial, last) (print or type)

Part B: Gender and Race Information

Check the boxes that apply to you.

Gender:

 

 

 Female 

 

 Male

Race/Ethnicity:

 American Indian or Alaskan Native

 Asian or Pacific Islander

 Black/African American (non-Hispanic)

 Hispanic

 White/Caucasian (non-Hispanic)

 Other (specify): 

Part C: Pro Bono and Observee/Observer Information

Providing the following information is optional and will be maintained separately from your application.

1. Once you have been qualified by the court to serve as a mediator:

a. Are you willing to be observed by a prospective mediator?

b. Are you willing to observe a prospective mediator in mediation pro bono?

2. Are you willing to accept appointment from the court to serve as a pro bono

mediator once a year?

Part D: Evaluative Mediation

 Yes 

 Yes 

 Yes 

 No

 No

 No

1. Are you willing to provide evaluative mediation in accordance with MCR 3.216(I)?

 Yes 

 No

MC 281b 

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MCR 3.216(G)