Parenting Plan with Reduced Fee (Responding) : Individual Forms : Our Services : Mediation West

Mediation is a voluntary process and Mediation West is one provider of this service.

If individuals choose any of the following:

Not to open a case with our office
Not to participate in an invitation from another party to mediate
Or have their case closed

They retain their right to resolve their issues through the use of a private mediator, the self-help section on the Nebraska Supreme Court Website, through a settlement conference between their attorneys, or any other means approved by the Court.

I am choosing to move forward with a voluntary case using Mediation West’s services and by doing so I acknowledge and agree to Mediation West’s Code of Conduct as stipulated in their Policy.

Code of Conduct - Behavior

By checking this box I agree to abide by the section labeled “Behavior.” I understand, in short, this means I will be polite and cooperative with everyone associated with my case (including the other participant(s), Meditation West staff, and mediators).

I agree

Code of Conduct - Mediation Progression

By checking this box I agree to abide by the section labeled “Lack of Mediation Progression.” I understand, in short, this means I will Meaningfully Mediate with the other party/parties in my case.

I agree

Fill out the form below to participate in an OPEN parenting plan case and apply for reduced fees.

If you want to participate and pay full 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)
Case Number provided to you by our office in your invitation to mediate
- (if you do not have this number please call our office at 308-635-2002)
Income verification to upload for each adult you are claiming in your household size
Your debit or credit to pay your processing fee of $39

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 *

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

Have you been court ordered to participate in mediation?

Yes
No
Not Sure

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

Do you currently have an attorney in this matter?

Your attorney’s name:

Your 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:

Why do you think the other parent sent the invitation to mediate?:

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 submit a $39 payment, complete the reduced fee application below, and upload the required income verification. Once your application for reduced fees is processed, you will receive a link with the balance due and instructions for submitting your payment.

Application for Reduced Fees

Mediation West offers a sliding fee scale based on your household size and income. You will need to provide income verification for each adult counted in your household size to pass audit requirements.

Number of Adults living in your household for which you can provide income verification:

Number of Children living in your household:

Current household gross annual income (before taxes/deductions):

Income verification must be provided for each adult used to figure household size. Please indicate which item(s) you will be uploading.

Your last two pay stubs
The first two pages of your last-filed tax return
Government benefits statement showing household income or benefit
Court order declaring you "in forma pauperis"
Verification of incarceration

Upload Requirement: Paystub #1 or other selected income verification from above.

Auditors require income verification to apply grant funds to your case.

No file selected

Click or drag here to add files

Upload Requirement: Paystub #2

When using pay stubs to verify income, a second pay stub is required.

No file selected

Click or drag here to add files

With my electronic signature, I certify that as of today’s date, my gross household income and the number of people living in my household are as I have indicated above. I understand that this information will be used in determining my eligibility for participation in the reduced fee grant program which utilizes federal and state funds; falsification of claims made on this application may subject the reporting party to federal or state penalties.

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.

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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 *

Select a Payment Method

Credit Card
Bank Account

Cardholder Name

Credit Card #

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?

Account Holder

First Name

Last Name

Account Type

Checking
Savings

Account Number

Routing Number

Your total payment will be

Your credit balance will cover

Your credit card will be charged

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Reduced Fee Application Processing

$39.00

Parenting Plan with Reduced Fee (Responding)

Mediation is a voluntary process and Mediation West is one provider of this service.

About You

About the Other Parent

About Your Child(ren)

About Your Case

About the Relationship

About Mediation

Application for Reduced Fees

Child-centered Mediation

Statistical Information

Sign Below

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