Style of the Case:   

Cause Number:  

Court Number: 

County Filed:  Travis Williamson Hays Bastrop Burnet Caldwell Comal Bexar Harris Dallas Tarrant Other

Name of Petitioner:  

Name of Respondent:  

Name/s of the Child/ren:  

Requested Mediation Date:   January February March April May June July August September October November December 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 2010 2011

Type of Mediation:   Full Day Mediaton (9:00 A.M. - 5:00 P.M.) -  Lunch Included Morning Mediation (8:30 A.M. - 12:30 P.M.) Afternoon Mediation (1:30 P.M. - 5:30 P.M.)

Type of Case:   Family Law Civil Litigation Collaborative Law DFPS

Location of Mediation:   700 E. 11th St., Austin, Texas (Downtown Austin)

Attorney Requesting Mediation: 

Mr./Ms.:  Mr. Ms.     First Name:     Last Name:  

Attorney Address:  

City:  

State:  

Zip:  

Phone Area Code: ()     Phone Number:   

Fax Area Code: ()     Fax Number:   

E-mail Address (required):   

Attorney Represents:   Petitioner Respondent Intervenor Ad Litem Pro Se Other

Other Party's Attorney:     

Mr./Ms.:   Mr. Ms.     First Name:     Last Name:  

Attorney Address:  

City:  

State:  

Zip:  

Phone Area Code: ()     Phone Number:   

Fax Area Code: ()     Fax Number:   

E-mail Address (required):   

Attorney Represents:   Petitioner Respondent Intervenor Ad Litem Pro Se Other

Please submit additional party/contact information or any other additional information regarding

the scheduling of the mediation in the comment section below.   

Note:  A blank Confidential Mediation Worksheet to be completed by both sides (requesting a summary

          of issues for mediation) will be forwarded along with the mediation confirmation discussed in 4. below. 

*** By submitting this Mediation Request Form, you are indicating that you have reviewed and agree to

      the mediation rates and cancellation policy of the Law and Mediation Offices of Mark W. Sims.