Application for Family Division Private Mediation & Collaborative Practice Panels

Mediators who wish to be added to the Family ADR database are encouraged to submit this online application.

Name:

Firm Name:

Address:

County:

Phone Number:

Email Address:

Confirm email

1. Check each panel for which you are applying:

Mediation

Collaborative Practice

2. Describe your education, including degrees and the dates received.

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Education/Degree Description	Date Received
Education/Degree Description	Date Received

3. Briefly describe the ADR training you have received. For each training, give the trainer's name, the dates attended, and the total hours.

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ADR Training Description	Trainer's Name	Date Attended	Total Hours
ADR Training Description	Trainer's Name	Date Attended	Total Hours

4. Describe the subject matter of five disputes for which you have been a mediator or collaborative attorney in the past five years, with dates. State whether you were a sole- or co-provider. (If you are applying for the mediation panel, describe 5 mediation cases handled. If you are applying for the collaborative practice panel, describe 3 collaborative practice cases handled. If you are applying for both panels, describe 5 mediations and 3 collaborative cases.)

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Describe the Subject Matter of Dispute	Date	Sole- or Co-Provider
Describe the Subject Matter of Dispute	Date	Sole- or Co-Provider

5. List other court ADR panels of which you are a member, specifying the processes for which you have qualified.

6. State the name of any organization for which you have provided ADR services during the past five years, giving the dates and the services you provided.

Click the Add button below to add more items, if needed.

Organization Name	Service Provided	Date Provided
Organization Name	Service Provided	Date Provided

8. What is your State Bar No.?

a. How many years have you been in active practice? In none, please explain.

b. What is or was the nature of your practice?

c. Are you certified in any specialty? If so, please list.

9. Describe any legal writing or lecturing/teaching you have done.

10. What is your ADR style?

11. List any languages, other than English, in which you can conduct ADR.

12. Describe your fee schedule, including any sliding-scale or pro-bono provisions, as of the date of this application.

13. Give any other information that should be considered in reviewing your application.

14. Please attach a recent resume or CV to an email and send it to FamilyADR@scscourt.org.

15. List the names and telephone numbers of three persons familiar with your mediation (for a mediator's application), litigation/evaluation and/or collaborative skills (for a collaborative practitioner's application). If you are applying for both panels, provide 3 mediation references and 3 collaborative practice references. You may not duplicate references.

Instead of entering a name, you may attach a letter of recommendation to an email and send it to FamilyADR@scscourt.org.

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Name	Phone
Name	Phone

Please read and sign the following agreement:

1. I agree to be bound by the ADR rules of the Santa Clara County Superior Court.

2. I agree to waive any and all claims against the Santa Clara Superior County Court in connection with my ADR services for a court-referred dispute.

3. I agree to submit any fee dispute arising out of my ADR services for a court-referred dispute to arbitration, either under Business and Professions Code section 6200 et seq. or by stipulation or court order.

4. I agree to adhere to the ethical standards for alternative dispute resolution providers as adopted by the court.

5. I agree to accept at least one pro bono case (maximum 10 hours per case) or modest means case a year.

6. I am in good standing with the State Bar of California.

7. I agree to indemnify, defend and hold harmless the Santa Clara County Superior Court, its judges, and employees from any claim, lawsuit, damages or liability of any kind, arising out of any conduct of mine in the rendering of services to any person or persons in connection with my inclusion on the ADR providers' list maintained by the Superior Court.

8. I agree to have my background information posted on the Court's ADR website.

I do

I do not

Signature:

Print Full Name	Date
Print Full Name	Date

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