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
Date of birth
Include if you would like to notify the other party of your self-referred mediation request by email.
Contact information
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.