Gender
M
F
X
Prefer not to say
Length of the relationship / marriage
Your age
Your ethnicity
Highest level of education achieved
Your income
$0 - $10,000
$10,0001 - $25,000
$25,0001 - $50,000
$50,001 - $75,000+
1 Was your mediation:
2 What types of issues did you mediate?
3 How long did the mediation last?
4 What specific issues were you facing?
5 Were you represented by counsel?
6 Did your lawyer attend the mediation with you?
7 Did the other party threaten you or cause you concern for your physical safety?
8 Did you have an opportunity to express your concerns to the court, your attorney, the mediation service, or mediator?
9 Were accommodations made to adequately address your concerns?
10 Were you willing to attend mediation?
11 Were you optimistic that mediation could result in a satisfactory resolution?
12 Did you feel prepared for mediation?
13 Did you feel the mediator was neutral and impartial?
14 Were you able to express your views and opinions in mediation?
15 How many issues were you able to reach agreement on?
16 If you reached agreements in mediation, do you feel they were fair?
17 Were you satisfied with the mediator?
18 Were you satisfied with mediation?
19 Did you benefit from mediation?
20 Would you recommend Mediation to others?
Why or Why Not?
22 Do you feel this was:
The name of your mediator is:
23 May we share this evaluation with the mediator?
Your Name
First Name
Last Name
Your Mediation Date
MM
DD
YYYY
