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Supreme court of virginia mediator profile form

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Please use black ink so this document will be legible when scanned.

  1. Name:

2. Agency, Organization or Practice: ___________________________________________

  1. Primary Street Address:

City: State: Zip: __________

4. Office Telephone Number: Extension:

  1. Home Telephone Number:

  2. Fax Number:

  1. Email Address:

  1. Web Address :____________________________________________________________

9. Education/Licensure:

___BA ___BS ___CDP ___CFP ___CPA ___DDS ___DMin
___EdD ___JD ___LCSW ___LLM ___LMFT ___LPC ___LPN
___MA ___ MBA ___MD ___MMin ___MPA ___ MEd ___MS
___MSW ___PhD ___RN
10. Other Court-Related Positions:
Commissioner in Chancery Guardian Ad Litem Magistrate
Probation Officer Retired Judge
11. Dispute Resolution Training Hours Received:
20-39 40-59 60-99 100-199 over 200
12. Number of Mediations Conducted:
less than 10 10-29 30-49 50-100 over 100

13. Numbers of Years Experience in Dispute Resolution:

0-2 3-5 6-10 over 10
14. Types of Dispute Resolution Services Provided:
Arbitration Conciliation Family Group Conferencing
Large Group Facilitation Mediation Neutral Case Evaluation
Ombuds Partnering Youth Accountability Conferencing
15. Hours Available:
8-5 M-F Evenings Weekends By Appointment
16. Languages in Which You Are Proficient:
American Sign Language Arabic Bosnian Bulgarian
Cambodian Cantonese Creole Filipino French
German Greek Hebrew Hindi Italian
Japanese Korean Laotian Latvian Mandarin
Mongolian Norwegian Persian (Farsi) Polish
Portuguese Romanian Russian Spanish Thai
Turkish Ukrainian Vietnamese
17. Types of Disputes in Which You Have Specialized Training and Experience:
ADA Adult Guardianship Aeronautics Business/Consumer
Child Abuse Neglect/Dependency Child Support Church
Community Construction Contract Corporate
Crisis Intervention Custody/Visitation Elder Employment
Environment Federal Securities Federal Workplace
Finances/Tax/Debt Collection Foreign Affairs Forensic
Healthcare Historic Preservation Housing (FHA) Insurance
Interstate Commerce Juvenile Justice Labor
Landlord/Tenant Law Enforcement Maritime
Medical Malpractice Mental Health Military
Multi-cultural Multi-party Parent/Teen Peer Mediation
Personal Injury Probate Property Distribution
Public Policy Real Estate Restorative Justice
Same-sex Relationships Special Education Spousal Support
U.S. Postal Service World Bank Workers Compensation
18. Location (Judicial Circuit) Where You Wish to be Listed:

Choose only 1 circuit. Leave blank if there is no circuit for which you want to be listed.

(View the circuit map of Virginia)

1 2 3 4 5 6 7 8
9 10 11 12 13 14 15
16 17 18 19 20 21 22
23 24 25 26 27 28 29
30 31
19. Customary Hourly Fee:
under $50 $50-74 $75-99 $100-124 $125-149
$150-199 over $200 sliding scale available
travel reimbursement
20. Are you willing to make reasonable accommodations to provide services for persons with

disabilities consistent with the Americans with Disabilities Act?

Yes No
Please Note: In the mediator database, we will also record types of certification held, mentor status, dates of certification and recertification, date next due for recertification, certification number, and MIS user name. Please see important notes on the next page.
______________________________________________ __________________________

Signature of Mediator Date

Please note that the information contained on your Mediator Profile Form will be entered in the mediator database maintained by the Office of the Executive Secretary and this same information will appear in the Searchable Mediator Directory located on the court website at Even without a profile form, the information you provide in your Application for Mediator Certification is entered in the mediator database and that same information is supplied to the Internet directory.
If you do not wish to be included in the Internet directory, please notify the office of Dispute Resolution Services in writing. Without such a request, you will automatically be included in the Internet directory. If you choose not to be included in the directory, you will still receive communications from the DRS office and be counted as a court-certified mediator.
From time to time, ADR organizations request the DRS office to provide contact information for our certified mediators. The organizations wish to disseminate information regarding ADR events, membership, and training and employment opportunities. If you wish to be EXCLUDED from the contact list, please let us know.
Please return this form to:
Dispute Resolution Services

Office of the Executive Secretary

Supreme Court of Virginia

100 North Ninth Street, Third Floor

Richmond, Virginia 23219

Telephone: 804-786-6455

Fax: 804-786-4760



Revised February 2014

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