Mediation Request Form - New

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Case Information

In the Matter of the Marriage of (and/or) In the Interest of:
i.e. Smith/Jones
Name of Person Submitting This Form  

Phone Number

Court Information


District Court
Ex. 250th

            County Court at Law #

Requested Mediation Date:

Until further notice, all mediations will occur via Zoom Videoconference over the duration of the COVID-19 Pandemic.
Information Regarding the Parties


Information Regarding the Child/ren
Name of Child Age
Attorney Requesting Mediation


Phone Number 
Fax Number 

Other Party's Attorney


Phone Number
Fax Number 

Contact Information

Fax Number

Contact Information

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 with Mark W. Sims 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 

By submitting this form, you agree to the cancellation policy (which applies to short notice cancellations) specifically outlined at Mr. Sims' website,