Form AOC-MED-ADR-7 "Application to Be Placed on the Mediator Roster" - Kentucky

What Is Form AOC-MED-ADR-7?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2018;
  • The latest edition provided by the Kentucky Court of Justice;
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  • Fill out the form in our online filing application.

Download a fillable version of Form AOC-MED-ADR-7 by clicking the link below or browse more documents and templates provided by the Kentucky Court of Justice.

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AOC- MED-ADR-7
For Office Use Only
Rev. 11-18
App Rec’d ______ / ______ /______
Page 1 of 3
l e x
e t
j u s t i t i a
Reviewed ______ / ______ / ______
Commonwealth of Kentucky
Court of Justice
Application Approved
q
YES
q
NO
www.courts.ky.gov
APPLICATION TO BE PLACED ON THE
Action Taken: ___________________
AP Part XII
MEDIATOR ROSTER
This application will be considered pursuant to criteria ordered as Rules of Administrative Procedure AP Part XII, Mediation
Guidelines for Court of Justice Mediators. Please read all instructions carefully.
Section I. General Information:
Name (Last, First, Middle): ___________________________________________________________
Mailing Address: ___________________________________________________________________
___________________________________________________________________
Phone: _____________________
E-mail: _____________________
County: _____________________
Section II. General Mediation:
(Complete this section if you would like to be placed on the roster as a General Mediator.)
Training and Experience
A mediator who offers to provide general mediation services should have the following minimum training and experience:
(a) Forty hours of training with an approved mediation training program covering communication skills; conflict resolution theory and
practice; mediation theory, practice, and techniques; the court process; and,
(b) Fifteen hours of participation in actual dispute mediation, in at least three cases, under the guidance of a mediator qualified under
these Guidelines or a mediation training center.
I have completed a general mediation training and mediation experience as required in Section II (a) and (b).
YES
NO
q
q
What organization provided your training and when? (See below.)
Training Provider
Location
Training Dates
Number of Hours
List areas of experience
(ex: contracts)
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
AOC- MED-ADR-7
For Office Use Only
Rev. 11-18
App Rec’d ______ / ______ /______
Page 1 of 3
l e x
e t
j u s t i t i a
Reviewed ______ / ______ / ______
Commonwealth of Kentucky
Court of Justice
Application Approved
q
YES
q
NO
www.courts.ky.gov
APPLICATION TO BE PLACED ON THE
Action Taken: ___________________
AP Part XII
MEDIATOR ROSTER
This application will be considered pursuant to criteria ordered as Rules of Administrative Procedure AP Part XII, Mediation
Guidelines for Court of Justice Mediators. Please read all instructions carefully.
Section I. General Information:
Name (Last, First, Middle): ___________________________________________________________
Mailing Address: ___________________________________________________________________
___________________________________________________________________
Phone: _____________________
E-mail: _____________________
County: _____________________
Section II. General Mediation:
(Complete this section if you would like to be placed on the roster as a General Mediator.)
Training and Experience
A mediator who offers to provide general mediation services should have the following minimum training and experience:
(a) Forty hours of training with an approved mediation training program covering communication skills; conflict resolution theory and
practice; mediation theory, practice, and techniques; the court process; and,
(b) Fifteen hours of participation in actual dispute mediation, in at least three cases, under the guidance of a mediator qualified under
these Guidelines or a mediation training center.
I have completed a general mediation training and mediation experience as required in Section II (a) and (b).
YES
NO
q
q
What organization provided your training and when? (See below.)
Training Provider
Location
Training Dates
Number of Hours
List areas of experience
(ex: contracts)
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
AOC-MED-ADR-7
Rev. 11-18
Page 2 of 3
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Pursuant to Section 2(3) of the Guidelines, any mediator who has not completed general mediation training and/or the
mediation experience as noted in Section II (a) and (b) above, and has engaged in a mediation practice prior to April 15,
2005, when these Guidelines were adopted, may be qualified by equivalent training and experience. Please describe below
what you believe is equivalent to the training and experience suggested by these Guidelines. (Use extra sheet if necessary.)
Section III. Family Mediation:
(Complete this section if you would like to be placed on the roster as a Family Mediator.)
Training and Experience
A mediator who offers to provide family mediation services should have the following minimum training and experience:
(a) Forty hours of training with an approved mediation training program covering conflict resolution, the mediation process, communication
skills, the psychological aspects of divorce on families, domestic violence, substance abuse, financial and property issues, paternity,
family law, and family or circuit court procedures. Family mediators are strongly encouraged to take general mediation training prior
to this training; and,
(b) Fifteen hours of participation in actual dispute mediation, in at least three cases, under the guidance of a family mediator qualified
under these Guidelines or a mediation training center.
I have completed a family mediation training and mediation experience as required in Section II (a) and (b).
YES
NO
q
q
What organization provided your training and when? (See below.)
Training Provider
Location
Training Dates
Number of Hours
List areas of experience
(ex: contracts)
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
AOC-MED-ADR-7
Rev. 11-18
Page 3 of 3
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Case Name:
Court:
Date:
Judge:
General Nature of Cause:
Duration of Mediation:
Supervisor/Mentor Name:
Supervisor Address:
Supervisor Phone:
Brief Description of Supervision received:
Pursuant to Section 2(3) of the Guidelines, any mediator who has not completed family mediation training and/or the mediation experience
as noted in Section III (a) and (b) above, and has engaged in a mediation practice prior to April 15, 2005, when these Guidelines were
adopted, may be qualified by equivalent training and experience. Please describe below what you believe is equivalent to the training
and experience suggested by these Guidelines. (Use extra sheet if necessary.)
I, _____________________________________________, swear/affirm that the information supplied on this application is
correct. I understand that falsifications, misstatements or misrepresentations above may disqualify me from being placed
on the mediators’ roster. I further certify that I have read and understand the Mediation Guidelines for the Court of Justice
Mediators, agree to adhere to the ethical guidelines as stated in Section 3, and agree to my name and contact information
being placed on the Mediators Roster with the Mediation Division of the Administrative Office of the Courts.
_______________________________________________
_______________________________
Signature of Applicant
Date
Please return this form to:
Administrative Office of the Courts
Mediation Office
1001 Vandalay Drive
Frankfort, KY 40601
Email: mediation@kycourts.net
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