DFPS Mediation Request Form

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Case Information

In the Interest of :
ex. In the Interest of: Smith/Jones
Requested Mediation Date:

 


Note:  


Mediations facilitated by Mark W. Sims, Attorney-Mediator, in cases involving the Department of Family and Protective Services 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:



Phone Number #:

Court Information

County


          
District Court
Ex. 250th

            County Court at Law #

          
Department of Family and Protective Services (DFPS)
DFPS Supervisor



Fax Number 


DFPS Caseworker




Attorney for the Department of Family and Protective Services:




Fax Number

Information Regarding the Child/ren
Name of Child

Information Regarding the Mother

Please include the name of the mother, if known.

Please include the name of the mother, if known.

Address






Attorney For The Mother



Fax Number


Information Regarding the Father
Please select 'This Father is unknown' ONLY IF the name of the father is listed as 'unknown' in the Original Petition. Indicating that 'This Father is unknown' when the father is named in the Petition could result in the DFPS Mediation Request Form being rejected and, under those circumstances, the entire form would have to be resubmitted to include the father's name.
Father

Please include the name of the father, if known.

Please include the name of the father, if known.

Address






Attorney for the Father



Fax Number
(
)
-


Information Regarding the Second Father
Please select 'This Father is unknown' ONLY IF the name of the father is listed as 'unknown' in the Original Petition. Indicating that 'This Father is unknown' when the father is named in the Petition could result in the DFPS Mediation Request Form being rejected and, under those circumstances, the entire form would have to be resubmitted to include the father's name.
Second Father

Please include the name of the second father, if known.

Please include the name of the second father, if known.

Address






Attorney for the Second Father



Fax Number


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:



Attorney's Fax Number


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:



Attorney's Fax Number


CASA (Court Appointed Special Advocate)

CASA Supervisor



CASA Supervisor's Fax Number 


CASA Volunteer


The name of the CASA Volunteer should be blank unless you have first included the name of the CASA Supervisor above. The CASA Supervisor's name is the name included in the Court Report.

The name of the CASA Volunteer should be blank unless you have first included the name of the CASA Supervisor above. The CASA Supervisor's name is the name included in the Court Report.

Information regarding the CASA Volunteer should be blank unless you first have included the CASA Supervisor's information above.

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

Clinic Supervisor



Clinic Supervisor's Fax Number 


Children's Rights Clinic Student Attorney





Include only if a private attorney is representing the child/ren. If the Children's Rights Clinic has been appointed as Attorney Ad Litem of the child/ren, please leave this section blank and complete the section above regarding the Children's Rights Clinic.
Attorney for the Child/ren:



Fax Number


 

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.