Self-referred mediation request form

Fill out the self-referred mediation form to request a custody or parenting time mediation appointment with Family Court Services. 

How this process works

  • Review the eligibility requirements:
    • Both parties must request and agree to the mediation
      • The second party must contact our office within 14 days of the initial request
      • Family Court Services will not contact a party on the behalf of another
    • At least one party must live in Hennepin County
    • Family Court Services cannot provide services when there is an active court order restricting one person’s contact with the other, unless the order allows for mediation services
  • Complete the form below
  • Notify the other party to contact Family Court Services to proceed with mediation services
  • Your request will be kept for 14 days
    • If the other party completes a request within 14 days, both parties will be contacted by phone to complete screening and intake prior to being assigned a mediator.
    • If we do not hear from the other party we will be unable to provide mediation services.  
Personal information
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Date of birth
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Include if you would like to notify the other party of your self-referred mediation request by email.
Contact information
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XXX-XXX-XXXX
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Include if you would like to receive confirmation of your request by email.
Children's information
List child(ren)'s first name, last name and age.
Additional information
Reason for self-referral
Select all that apply.
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