Vermont Divorce Mediation Completion Form
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Case Data Divorce Mediation Completion Information

Note to Mediators: At the close of each case, OR IF NO ACTIVITY ON CASE AFTER 90 DAYS, please complete this form and
submit it or you can print it and return it to the program with your monthly invoice. If your final bill for a case, this form
must be completed in order for the invoice to be processed.
1. Mediator's name:
2. Date of completion:
3. County in which the case is or would be filed:
4. Assigned Intake ID # (e.g. 10-JKLK):
Docket number (if available with permission):
5. Names of parties (if available with permission):

6.

How many sessions?

7.

How many total case minutes?

8.

How many children were affected by this mediation?
6-12
Birth-5
Number of children at each age?

9.

1-3

If more, how many?

4-6
15-60

90-180

If more, how many?

13-18

Dependent over 18

65-90

Issues Mediated: Please check issues mediated and agreement information for each issue.
Agreement Reached

Mediated
financial - assets/debt