Parenting Plan (Full Fees) : Individual Forms : Our Services : Mediation West

Fill out the form below to open a NEW parenting plan case and pay full fees.

If you want to apply for reduced fees, please complete this form instead.

If you need to mediate issues not related to a parenting plan, please complete this form instead.

Before you begin make sure to have the following:

15-20 minutes to complete the form (information does not save and will not submit until all required fields are provided)
Contact information for the other parent and anyone else you would like us to provide information to
Income verification to upload for each adult you are claiming in your household size
Your debit or credit to pay your processing fee of one of the following:
- $139.00 in order to schedule your Individual Private Session (with remaining fees due before additional Regular Mediation Session)
- $439.00 to pay for both Individual Private Session and Regular Mediation Sessions at once

How did you hear about us?

About You

Legal Name

First Name *

Last Name *

Preferred Name

First Name

Last Name

Mailing Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Phone Number

I agree to accept texts at this number:

Email (if you don’t have an email address, enter email@noemail.com)

I regularly check this email:

What is your preferred form of contact?

About the Other Parent

Legal Name

First Name *

Last Name *

Preferred Name

First Name

Last Name

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Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Home Phone (if the other parent doesn’t have a landline, enter all 0s)

Cell Phone (if the other parent doesn’t have a mobile phone, enter all 0s)

Email (if you don’t know the other parent’s email address, enter email@noemail.com)

What do you anticipate their preferred form of contact to be?

About Your Child(ren)

Your mediator will work with you to develop a parenting plan that considers the personality and developmental stage(s) of your children. Click all age ranges of the children that will be included in your parent plan:

Stage 1 – Birth to 6 Mo.
Stage 2 – 6 Mo. to 18 Mo.
Stage 3 – 18 Mo. to 3 Yrs.
Stage 4 – 3 Yrs. to 6 Yrs.
Stage 5 – 6 Yrs. to 12 Yrs.
Stage 6 – 13 Yrs. to 19 Yrs.

Please tell us about the current living arrangements for each child and the schedule for each parent’s time with them:

From your perspective, are those arrangements working well?

Always
Often
Sometimes
Never

Are there any special needs we should know about for your child(ren)?

About Your Case

Is your case filed in court?

Yes
No
Not Sure

County in which case is/will be filed:

Have you been court ordered to participate in mediation?

Yes
No
Not Sure

If court ordered what is the date of your next hearing?

Case # CI-:

Judge:

Do you currently have an attorney in this matter?

Your attorney’s name:

Your attorney’s firm:

Does the other parent currently have an attorney in this matter?

Yes
No
Not Sure

Other Parent’s attorney:

Other Parent’s attorney’s firm:

About the Relationship

Length of time together:

Never in a relationship
Less than 1 year
1-5 years
5-10 years
10+ years

Length of time married:

Never
Less than 1 year
1-5 years
5-10 years
10+ years

Length of time separated:

Still in the same household
Less than 1 year
More than 1 year

Length of time divorced:

N/A
Less than 1 year
1-5 years
5+ years

Is there a current protection order in place?:

Yes
No
Not Sure

Does the current protection order include the children?

Yes
No
Not Sure

Is there a history of protection orders or police calls?

Yes
No
Not Sure

If so, briefly describe the circumstances:

Do you think the other parent is expecting to hear from us?

How do you think the other parent will respond to the invitation to mediate?:

If you plan to mediate a MODIFICATION to a Parenting Plan already filed in court please check boxed below that apply. If this is a NEW or NOT YET FILED parenting plan skip to the next section.

What area(s) of concern would you like to mediate that we can share with the other party?

Parenting Time: Regular Schedule
Parenting Time: Summer Schedule
Parenting Time: Holiday Schedule
Education: School Enrollment
Education: Extra Curricular
Education: Academic Program(s)
Transportation: Parent Move/Relocation
Transportation: Safety

Selected area(s) of concern will be shared with the other parent in your case when an invitation to mediate is extended.

Have you talked with the other parent about the area(s) of concern you have selected above?

Is there anything else you’d like us to know as we begin working on your case?:

About Mediation

By signing below, you consent to mediate with the other parent identified above according to terms of current Mediation West Policy. To read the full policy click here. Highlights of the policy include:

Mediation is voluntary and agreements cannot be forced upon you. You have the option to review any agreements with an attorney before signing if you wish.
Mediation West keeps the content of your sessions confidential but may need to report process information such as progress and scheduling.
You agree to keep the content of the session confidential and agree:
- Not to record or transcribe sessions.
- Identify anyone who could potentially overhear a session if joining by phone or video conference.

Recordings/transcriptions of sessions are not admissible in court and allowing other people to listen to sessions is strictly forbidden and may void any agreement reached.

Mediation West may share information about your case under certain circumstances (to read the full policy click here). If you would like us to release/receive information to/from someone, we need your authorization by checking the corresponding box below:

Release of Information to:

1. My Attorney and his/her firm as listed above
2. Other professional(s)

Professional’s Name:

Professional’s Phone Number:

Professional’s Email:

Release of Information to:

3. My New Spouse/Significant Other (not party you are mediating with)

Individual’s Name:

Individual’s email:

Release of Information to:

4. Additional Family Member

Individual’s Name:

Phone number:

Individual’s email:

Release of Information to:

5. Other Support Person

Individual’s Name:

Phone number:

Individual’s email:

Fees for services are due and payable before sessions can be scheduled and refunds are limited (to read the full policy click here). When opening your case today, you will need to do one of the following:

submit a payment of $139.00 to break your payment into two parts. (This payment will allow us to schedule your individual session. An additional payment of $300.00 will be required before we can schedule your joint/caucus session.) OR
submit a $439 payment to take care of your initial fees. (This payment will allow you to schedule your individual session and first joint session. Additional payments will only be required if your mediation requires multiple joint sessions.)

Child-centered Mediation

To read the full policy on Child-centered mediation, click here. Highlights include:

Children are not asked to make decisions; parents are given the opportunity to hear from them how parenting from two households is affecting them.
Children’s time with their consultant is explained as private but not secret. Children are free to share anything they would like about the activities they participate in; parents agree not to push for children to share if they choose not to.
Children may choose to meet with parents before the parents mediate. Children may choose to deliver messages to the parents through their consultant. Children may have no messages for parents directly and parents may only receive a report from the consultant.

Choose one:

By signing below, I give my consent for Mediation West to hold mediation session(s) with my minor child(ren) and to contact them for mediation preparation or follow-up. I understand this consent can be withdrawn in writing at any time.
By signing below, I acknowledge that Mediation West has offered child-centered mediation services to my family but choose not to participate at this time.

Choose one:

I currently have sole legal custody and decision- making authority for my child(ren).
The other parent and I have joint legal custody and decision-making authority for my child(ren).
I am unsure about the current legal custody/decision-making authority for my child(ren).

Statistical Information

As a Nebraska ODR-approved mediation center, Mediation West is subject to reporting requirements which includes the following statistical information. Your answers to these questions will assist us in completing these reports.

Gender

Male
Female
Non-binary
Choose not to disclose

Ethnicity

White
Native American
African American
Hispanic
Asian
Two or more races
Choose not to disclose

Other (indicate)

Sign Below

I agree that clicking the "I Accept" button and entering my full name below shall constitute an electronic signature, and along with processing my payment, constitute valid evidence of my consent to mediate under the policies of Mediation West. I understand I am solely responsible for reviewing and understanding all the terms and conditions. I agree the electronically stored copy of this consent is enforceable to the same extent as if the documents and records were originally generated and maintained in printed form.

Electronic Signature:

I Accept

Full Name:

First Name *

Last Name *

Parenting Plan Fee

A partial deposit of $139.00 allows us to schedule your individual session. A second payment of $300.00 will be required prior to scheduling your first regular session. A full deposit of $439 allows us to schedule your individual and first regular session.

$139.00
$439.00

Credit Card Information

Cardholder Name

Credit Card #

Visa MasterCard American Express Discover

Expiration Date

Security Code

Cover the fee associated with this online transaction?

Yes, I will donate {transaction_fee} to cover the cost of this transaction.

Cover the fee associated with this online transaction?

Your total payment will be

Your credit balance will cover

Your credit card will be charged

Your bank account will be charged

Parenting Plan (Full Fees)

About You

About the Other Parent

About Your Child(ren)

About Your Case

About the Relationship

If you plan to mediate a MODIFICATION to a Parenting Plan already filed in court please check boxed below that apply. If this is a NEW or NOT YET FILED parenting plan skip to the next section.

Selected area(s) of concern will be shared with the other parent in your case when an invitation to mediate is extended.

About Mediation

Child-centered Mediation

Statistical Information

Sign Below

Credit Card Information

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