TORONTO MEDIATION CENTRE
Worker Referral Form
Date: / Referring Agency:Family Service Worker: / Telephone & Extension:
E-mail: / Supervisor:
Children’s Worker: / Telephone & Extension:
E-mail: / Supervisor:
Agency Lawyer: / Telephone & Extension:
Stage of Court Application: / Pre-litigation
Litigation initiated
Litigation in process
Has the Office of the Children’s Lawyer been contacted? Yes No
If no, please explain:
Have all parties consented to CPM? Yes No
If no, please explain:
CASE INFORMATION
Referral suggested by:Judge Only CAS Lawyer
Judge’s Name: ______
Counsel Parents
CAS Worker Other
/ Court Location:
Next Court Date:
Nature of Current Court Application:
Supervisory Order Crown Wardship
Society Wardship Other (Define)
Is there a concurrent CLRA application? Yes No
Is there a parenting capacity assessment planned or underway? Yes No
If yes, explain:
Is there a matter before the criminal courts related to the safety of any family member? Yes No
If yes, explain:
Has there been a finding that the children are in need of protection?
Yes, all the children. No finding yet, application pending.
Yes, some children. CAS does not plan to seek a finding.
Interim finding, without prejudice. Not applicable (e.g adoption case).
Anticipated issues of focus in CPM:
Child custody and/or placement Crown wardship/order review
Access to children Adoption openness arrangement
Terms/conditions of a supervision order Conditions for return of child to family care
Permanency planning Other (explain):
Please check if the following applies:
Language Interpreter required Language: ______
Key issues for Mediation:
Parties involved in Mediation:
Name: / Relationship to children:Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Name: / Relationship to children:
Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Name: / Relationship to children:
Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Name: / Relationship to children:
Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Name: / Relationship to children:
Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Name: / Relationship to children:
Address:
City: / Phone:
Lawyer: / Lawyer’s Phone:
Child’s Name: /
Date of Birth:
Lawyer:
Lawyer’s phone:
Current CAS Status
Temporary Care Other (Define):
Pre-litigation
Litigation initiated
Litigation in process
Child’s Name: /
Date of Birth:
Lawyer:
Lawyer’s phone:
Current CAS Status
Temporary Care Other (Define):
Pre-litigation
Litigation initiated
Litigation in process
Child’s Name: /
Date of Birth:
Lawyer:
Lawyer’s phone:
Current CAS Status
Temporary Care Other (Define):
Pre-litigation
Litigation initiated
Litigation in process
Child’s Name: /
Date of Birth:
Lawyer:
Lawyer’s phone:
Current CAS Status
Temporary Care Other (Define):
Pre-litigation
Litigation initiated
Litigation in process
Child’s Name: /
Date of Birth:
Lawyer:
Lawyer’s phone:
Current CAS Status
Temporary Care Other (Define):
Pre-litigation
Litigation initiated
Litigation in process
Please return this form to Karen Ehrlich, Program Manager, by fax at (416) 572-2653 or by e-mail at .