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2. First Name*
3. Last Name*
5. Date of Service*
   Date of Service
6. Hours Service performed (ex. 3:00-5:00 p.m.)
8. Number of Hours, rounded to the nearest 15 minutes. (Please record all mediations as 4 hours)*
10. Type of Service*

    1. Mediation
    2. Outreach
    3. Office

    1. Training
    2. Intake
    3. Other
12. If this was outreach or training, please place information below:
14. If this was a mediation, please fill in the fields below:
16. Case Number
17. Session Number
18. Number of Participants
20. Co-Mediator Name
22. Was an agreement reached?

    1. Yes - a verbal agreement was reached
    2. Yes - a written agreement was reached
    3. No
24. If case was not mediated, list reason:
26. Is this case closed?

    1. Yes
    2. No
28. If case is still open, please complete the following:
30. Date of next mediation
    Date of next mediation
31. Time of Mediation
    Time of Mediation
33. Please comment briefly on the mediation overall, noting any positive feedback or any concerns that may need staff follow up. Your feedback helps us improve our program.
35. If you would like staff to follow up with you regarding your feedback, please provide the information for your preferred method of contact below:
37. Phone number
38. Email
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit

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