FRANKLIN COUNTY
COURT OF COMMON PLEAS
DIVISION OF DOMESTIC RELATIONS
AND JUVENILE BRANCH
373 South High Street

Columbus, Ohio 43215

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JUDGES

DANA S. PREISSE
KIM A. BROWNE
ELIZABETH GILL
TERRI B. JAMISON
JAMES W. BROWN
Marya C. Kolman, Esq.
Director of Mediation Services
614-525-5872
FAX: 525-3748
E-Mail:

Thank you for your recent request for information regarding our mediation program. I am enclosing a brochure that describes the program. If you would like to participate in mediation, please complete the enclosed information form and mail it to the following address:

Mediation Services

373 South High Street, Third Floor

Columbus, OH 43215-4595

You may also fax this request to (614) 525-3748.

Once we have received the request form from you, we will schedule a mediation session with an impartial mediator for you and the other participants. Scheduling letters with the date and time of the mediation are sent to all participants. Mediation sessions last from two to two and one half hours. If you need an evening session, please write that on your form. Please also indicate any other scheduling requests. Please also let us know if you or another participant will need an interpreter to participate in the mediation session.

If you have any questions or would like more information about the program, please call us at (614) 525-6640.

Sincerely,

Marya C. Kolman

REQUEST FOR MEDIATION

PLEASE PRINT CLEARLY

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Your Name (First Name, Middle Initial & Last Name) Relationship to Child (if applicable)

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Street Address E-mail

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City State Zip code

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Home Telephone Number Cell Phone

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Name(s) of Child(ren) Date(s) of Birth

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Child Support Case # (if any) Court Case # (if any)

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Has Children’s Services been involved with this child? If yes, when and why? Is case open?

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Who has legal custody of the child(ren)?

Is there a Protection Order between you and the other party? Yes______No ______

How was paternity established? (if parents were not married) ______

Contact Information for Other Participant(s)

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Name (First Name, Middle Initial & Last Name) Relationship to child (if applicable)

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Street Address

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City State Zip Code

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Telephone Number Home Cell Phone Work Phone

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Date Signature of Person Making Request