Order Of Referral To Mediation Form - Lake County, Illinois Page 2
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1
2Orders of Protection
The parties represent to the court as follows: (at least one box must be checked)
No orders of protection have ever been entered involving the parties to this case, or
The parties are, or have been in the past, involved in a proceeding(s) under the Illinois Domestic Violence Act.
A current order of protection prohibits one of the parties from having any contact with the other party.
If the parties to mediation are subject to an order of protection which prohibits contact, they shall attend separate
orientation and mediation sessions only.
Notice to the Parties
The parties are expected to mediate their dispute in good faith. Failure to attend a mediation session or failure to
participate in mediation in good faith may subject a party to sanctions. Sanctions may include an assessment of
mediation costs and/or attorney’s fees incurred by the other party.
At the initial orientation session, the mediator shall inform the parties of their rights and obligations in mediation.
Mediation shall terminate upon the following:
a. When all issues have been resolved, or
b. When an individual necessary to facilitate settlement of the dispute is not present, or
c. When, in the opinion of the mediator, no purpose would be served by continuing the mediation, or
d. When the mediator determines that an impairment exists that hinders the ability of the parties to negotiate
safely, competently, or in good faith, or
e. Upon order of court for good cause shown.
Failure to appear on the date(s) scheduled and/or comply with the terms in this order may subject a party to
sanctions pursuant to Supreme Court Rule 219(c), including but not limited to attorney’s fees, monetary
sanctions, and/or dismissal for want of prosecution.
Dated at Waukegan, Illinois this
Enter:
day of
, 20
JUDGE
Prepared by:
Name: ____________________________________________
Attorney’s Name: ____________________________________
Address: __________________________________________
City: ______________________________ State: __________
Phone: ______________________Zip Code: _____________
Fax: ______________________________________________
ARDC #: __________________________________________
Page 2 of 2
171-329 (Rev. 06/13)
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