DFPS Mediation Request Form

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Case Information
In the Interest of : ex. In the Interest of: Smith/Jones
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***Note:  All DFPS mediations facilitated by Mark W. Sims, Attorney-Mediator, begin at 9:30 A.M.

 

Mark's preference is that mediations be scheduled at his offices in downtown Austin, absent specific circumstances that would require that the mediation occur elsewhere.

Note: 

This form is to submit a request for a full-day mediation on a specific date.  The mediation is not confirmed until the parties have received written confirmation from Mark W. Sims, Attorney-Mediator, that the mediation has been scheduled on the requested date.  

 

Name of Person Submitting the Form:
( )
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Court Information
County

District CourtEx. 250th
County Court at Law #
#
Department of Family and Protective Services (DFPS)
DFPS Supervisor
( )
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DFPS Caseworker

Attorney for the Department of Family and Protective Services:

( )
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Information Regarding the Child/ren
Name of Child

Information Regarding the Mother

Address



Attorney For The Mother
( )
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Information Regarding the Father


Address



Attorney for the Father
( )
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Information Regarding the Second Father


Address



Attorney for the Second Father
( )
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Information Regarding the Intervenor
Choose 'Otherwise Related to the Child' if the Intervenor is a blood relative whose Relationship is not listed. Chosse 'Symbolic Relative' if the Intervenor has a close relationship to the child but is not related by blood.

Address



Intervenor's Spouse
Choose 'Otherwise Related to the Child' if the Intervenor is a blood relative whose Relationship is not listed. Chosse 'Symbolic Relative' if the Intervenor has a close relationship to the child but is not related by blood.

Attorney for the Intervenor:
*( )
* -
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Information Regarding the Second Intervenor
Choose 'Otherwise Related to the Child' if the Intervenor is a blood relative whose Relationship is not listed. Chosse 'Symbolic Relative' if the Intervenor has a close relationship to the child but is not related by blood.

Address



Second Intervenor's Spouse
Choose 'Otherwise Related to the Child' if the Intervenor is a blood relative whose Relationship is not listed. Chosse 'Symbolic Relative' if the Intervenor has a close relationship to the child but is not related by blood.

Attorney for the Second Intervenor:
*( )
* -
*


CASA (Court Appointed Special Advocate)

CASA Supervisor
( )
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CASA Volunteer


Children's Rights Clinic (through the University of Texas School of Law)

Clinic Supervisor
( )
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Children's Rights Clinic Student Attorney


Attorney for the Child/ren:
( )
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This form is to submit a request for mediation on a specific date.  The mediation is not confirmed until the parties have received written confirmation from Mark W. Sims, Attorney-Mediator, that the mediation has been scheduled on the requested date.  

If the mediation cannot be scheduled for whatever reason, you will be notified as quickly as possible but no later than the next day after submitting the form.    

Once the mediation is scheduled, confirmations will be sent out to the parties via the contact information submitted with this form. 

If you do not receive any communication from Mark W. Sims by the next business day after requesting a mediation date or completing this form, please contact Mark W. Sims at texaslaw@austinmediation.com. 

By submitting this form, you agree to the cancellation policy (for last minute cancellations) specifically outlined at www.austinmediation.com. 

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