Family Case Intake

Central Mediation Center (CMC) agrees to provide mediation services conforming to established standards of practice for mediators as set by the Nebraska Dispute Resolution Act, and other pertinent federal and state laws and regulations.

Each potential mediation will be screened by CMC staff to determine whether it is appropriate for mediation.  At its discretion, CMC may decline to mediate the dispute or may terminate the mediation at any time.

Agreement to Participate in Mediation

I consent to participate in mediation arranged and conducted by Central Mediation Center and agree to the following terms.

1. Agree to enter into mediation in good faith, to cooperate with the mediator, to listen to the other party, to be truthful, and to make an effort to develop realistic solutions.

2. Everything that is said in mediation is confidential, is intended for use as settlement discussion only, and may not be used as evidence in future court proceedings, or for any other purpose except: information relating to child abuse or neglect crimes committed on the premises, or credible threats to commit bodily injury sessions that are open to the public or conducted in a public setting information may be shared while consulting with other center staff on cases and agreements signed by all parties.

3. I understand no weapons, physical conflict, or use of recording devices are permitted at the Center or any mediation site.

4. I understand CMC mediators and employees do not represent any party and are not authorized to give legal advice. I understand I may seek legal or other professional advice at any time prior to, during, or after the mediation session(s).

5. In consideration for the session(s), I agree to hold CMC, its employees, board members, and mediators completely harmless and without legal or financial responsibility.  I further agree not to involve, depose, or subpoena CMC, it' s employees, board members, mediators, or records in any claim or court proceeding.

6. I understand the mediator may meet and communicate separately with each party before, during, or after mediation to explore agreement terms and processes, and may send draft proposals to the parties and their attorneys for review and revision.

7. I authorize CMC to contact my attorney, referring entity, and/or court personnel regarding the status of mediation case and any proposed agreements. I acknowledge that CMC has advised me to have any agreement reached in mediation reviewed by an attorney before I sign it.

8. *Fees*: I agree to pay the following fees to Central Mediation Center: 

                a. Processing Fee: $25 required per person for intake. Non-refundable.

                b. Mediation: $250 flat-rate fee per person required prior to scheduling mediation session. If mediation exceeds two hours, mediation will be billed at $125 per mediated hour, per person. Parties may qualify for a reduced fee rate with income verification - instructions to apply for reduced fee are in the form below - processing fee is still required. Pre-payment at a reduced fee rate is still required prior to scheduling mediation. ***If mediation is provided regarding financial calculations, i.e. child support/alimony, and/or a property settlement, those portions of mediation will be billed at $150 per mediated hour, per person.

                 c. Cancellation: $25 fee for cancelling a scheduled mediation session less than 48 hours (2 business days) of the scheduled time; $50 fee for cancelling a scheduled mediation session less than 24 hours (1 business day) of the scheduled time; $100 fee if I am a "no show." ***If a party requests to reschedule/cancel a report will be sent to the Court to notify the Judge of the request to reschedule/cancel.     
                 
                 d. Pending Balances: Central Mediation Center will require all prior balances to be paid prior to opening another case for mediation.                                  
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Marital Status
Any protection orders in place
If you would like to apply for a reduced fee, check yes and you will be instructed via email on how to submit income verification.
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Notes: Please do not include any URLs in the form. You might have to click "submit" twice.

After submission, please return to our mediation forms page to pay the $25.00 required processing fee.