Mediator Profile Form (EADR-1005)

Use this form to generate a code that you can send to DRS to update your mediator profile information. Please note that all of the information below, except for the information entered into "Private Contact" box, will appear online in the Searchable Mediator Directory. When you are ready to submit the information, press the "Generate Email Code" at the bottom of this page, copy the code, and email it to drsapplications@vacourts.gov.

Contact

Organization: Mailing Address: Apt/Unit/Suite/etc.: City: State: Zip Code: Work/Office Phone: Work Phone Ext: Home Phone: Fax: Email: Web address:

Private Contact (DRS-Only)

The information in this box will be considered private. List any contact information that you would not want to appear online in this box. Any information entered into the fields outside of this box will be displayed on the online directory.

Organization: Mailing Address: Apt/Unit/Suite/etc.: City: State: Zip Code: Work/Office Phone: Home Phone: Fax: Email:

Circuit-Court Family CVS

If you are a circuit court family mediator, are you willing to mediate circuit court-referred CVS cases at no cost to the parties under Virginia Code §20-124.4? You will be able to submit a DC-40 invoice for the state rate of $120 per appointment.

Yes
No

Location (judicial circuit) where you would like to be listed

Click here to see the circuit map of Virginia

Circuit:

Mediator Description (255 character limit)

Feel free to write a short description of your mediation practice to help the public and potential clients decide on a mediator. DRS will not check or edit the description for errors. DRS reserves the right to reject a description, and would notify the mediator.

0/255

Email Code

If the information above is correct, press the "Generate Email Code" button below. Copy the entire code that appears below the button and email it to drsapplications@vacourts.gov.

Please note that the information contained on your Mediator Profile Form will be entered in the mediator database maintained by the Office of the Executive Secretary and this same information will appear in the Searchable Mediator Directory located on the court website at www.vacourts.gov. Even without a profile form, the information you provide in your Application for Mediator Certification is entered in the mediator database and supplied to the online directory.

If you do not wish to be included in the online directory, please notify the office of Dispute Resolution Services in writing. Without such a request, you will automatically be included. If you choose not to be included in the directory, you will still receive communications from the DRS office and be counted as a court-certified mediator.

From time to time, ADR organizations request the DRS office to provide contact information for our certified mediators. The organizations wish to disseminate information regarding ADR events, membership, and training and employment opportunities. If you wish to be EXCLUDED from the contact list, please let us know.

Mediator Profile Form (EADR-1005)

Certification Number

Name