2. To help us to maintain the quality of the mediation program, please answer all of the questions below. Your responses will be kept confidential and will be used to evaluate our services. No identifying information about you will be released.
4. Case Name
5. Case Number
7. Mediator Name
8. Date of Mediation
   Date of Mediation
10. What is your relationship to the child(ren)?

    1. Parent
    2. Other
12. If Other, please specify
14. The following questions ask about your experience during the mediation session. Please check one box for each question.
16. How clearly did the mediator explain what would happen in mediation?

    1. Not at all clearly
    2. Somewhat clearly
    3. Very clearly
    4. The mediator didn't explain what would happen
18. Were you able to talk about the issues and concerns that were most important to you?

    1. I was able to talk about none of the issues and concerns that were most important to me.
    2. I was able to talk about some of the issues and concerns that were most important to me.
    3. I was able to talk about most of the issues and concerns that were most important to me.
    4. I was able to talk about all of the issues and concerns that were most important to me.
20. Did you have the opportunity to express your feelings in mediation?

    1. Not at all
    2. Somewhat
    3. Very much
22. Did the mediator keep you focused on what was best for the children?

    1. Not at all
    2. Somewhat
    3. Very much
24. Do you understand the other parent’s point of view better than you did before mediation?

    1. Not at all better
    2. Somewhat better
    3. Much better
26. How much did the mediation help you to think about different ways to work with the other parent?

    1. Not at all
    2. Some
    3. A lot
28. Was the mediator active enough in helping you to work out the issues in the dispute?

    1. No
    2. Yes
30. How well did the mediator understand what was important to you?

    1. Not at all
    2. Somewhat
    3. Very well
32. Did the mediator treat you with respect?

    1. Not at all
    2. Somewhat
    3. Very much
34. Did the mediator treat you fairly?

    1. Not at all
    2. Somewhat
    3. Very much
36. Did the mediator push too hard to get you to settle?

    1. Yes, the mediator pushed too hard
    2. No, the mediator did not push too hard
38. What was the outcome of the mediation?

    1. We reached agreement on all the issues in the case
    2. We reached agreement on some of the issues in the case
    3. We didn’t reach agreement on any issues in the case
42. If you reached agreement, please answer the following questions:
44. Are you clear about the details of the agreement?

    1. Not at all
    2. Somewhat
    3. Very much
46. Do you have any doubts that the agreement will work?

    1. Not at all
    2. Somewhat
    3. Very much
50. How satisfied are you with the outcome of the mediation?

    1. Very Unsatisfied
    2. Unsatisfied
    3. Satisfied
    4. Very Satisfied
52. Regardless of the outcome, how satisfied are you with your overall experience in the mediation session(s)?

    1. Very Unsatisfied
    2. Unsatisfied
    3. Satisfied
    4. Very Satisfied
54. Would you use mediation again?

    1. Yes
    2. No
    3. Possibly
56. Why or Why Not?
58. Please let us know more about your experience:
60. Things I liked about the mediation:
62. Things I didn't like about the mediation:
64. Please help keep us informed about mediation services by answering the following questions about yourself. Your answers will remain completely confidential.
66. Zip Code
67. What languages do you usually speak at home?
69. Age Range

    1. 18 - 24

    1. 25 - 44

    1. 45 - 64

    1. 65+
71. Gender

    1. Male

    1. Female
Leave This Blank:


73. 1. Receive an email copy of this form.
74. Email address

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