17Apr2024 Intake Forms and Payment - PDF Templates

Wednesday, November 20, 2024

Item - 17Apr2024 Intake Forms and Payment Image-1 0

849 E State St. Suite 107

Eagle, ID 83616

(208) 447-7715

www.EagleRiverMediation.com

CONFIDENTIAL INTAKE FORM

PERSONAL INFORMATION

LEGAL NAME

Michael McFarlane

PHONE NUMBER

(206) 850-1767

BIRTHDATE

Friday, July 25, 1975

E-MAIL

mcfarlanemj@gmail.com

ADDRESS

130 W Horizon Dr

BOISE, Idaho, 83702

DO YOU HAVE A CASE NUMBER?

NAME OF THE OTHER PARTY IN THIS CASE

Jessica McFarlane

REFERRED BY

Google

FOR WHAT PURPOSE ARE YOU SEEKING MEDIATION

Divorce with a child(ren) under 18

ARE YOU LIVING WITH THE OTHER PARTY

Yes

CHILDREN

NUMBER OF CHILDREN

FIRST CHILD'S NAME

Hana McFarlane

FIRST CHILD'S BIRTHDATE

05272002

FIRST CHILD'S AGE

SECOND CHILD'S NAME

Meg McFarlane

SECOND CHILD'S BIRTHDATE

05032006

SECOND CHILD'S AGE

THIRD CHILD'S NAME

Jake McFarlane

THIRD CHID'S BIRTHDATE

07152009

THIRD CHID'S BIRTHDATE

07152009

THIRD CHILD'S AGE

ARE YOU CURRENTLY FOLLOW A PARENTING SCHEDULE OR CUSTODY SCHEDULE?

EMPLOYMENT INFORMATION

ARE YOU CURRENTLY EMPLOYED

Full time

OCCUPATION

Business owner

EMPLOYER

VPI

GROSS ANNUAL INCOME

108000

DO YOU HAVE THE POTENTIA

L TO RECEIVE A BONUS OR

HAVE AN ADDITIONAL INCOM

E SOURCE

Additional i

ncome source

PROVIDE DETAILS ABOUT YOUR BONUS OR ADDITIONAL INCOME SOURCE

Rental property

EDUCATION INFORMATION

HIGH SCHOOL ATTENDED

Shorecrest

GRADUATION YEAR

1994

COLLEGE/UNIVERSITY

Western Washington University

GRADUATION YEAR

1998

WHAT DEGREE DID YOU ATTAIN?

BA Sociology

ATTORNEY INFORMATION

HAVE YOU RETAINED OR CONSULTED WITH AN ATTORNEY?

DO YOU PLAN TO CONSULT WITH AN ATTORNEY

ADDITIONAL INFORMATION

WHAT ARE THE ISSUES YOU WOULD LIKE TO RESOLVE IN MEDIATION?

Create plan for time with kids, financial agreement and establish separation agreement.

WHAT HAS BLOCKED YOU FROM RESOLVING THIS CONFLICT WITH THE OTHER PARTY?

Unsure of how to proceed and looking for direction.

WHAT DO YOU AND THE OTHER PARTY AGREE ON, IF ANYTHING?

We have talked numerous times about this, next steps, and what separation looks like and have agreed on most topics.

WHAT DO YOU AND THE OTHER PARTY DISAGREE ABOUT, IF ANYTHING?

Can't think of anything at this point.

WHAT IS MOST IMPORTANT TO YOU?

Developing next steps and acting on what needs

to be done.

WHAT DO YOU BELIEVE IS MOST IMPORTANT TO THE OTHER PARTY?

How to separate business and assets. I have put together balance sheets showing what I see as a 50/50 split. Jess wants someone with experience to review this to ensure we aren't making any big mistakes as it relates to business/assets.

ARE THERE THINGS THE OTHER PARTY MIGHT SAY THAT WOULD CAUSE YOU DISTRESS OR CAUSE YOU TO LOSE YOUR TEMPER?

IF THE OTHER PARTY DOES NOT AGREE WITH YOUR PREFERRED OUTCOME, WHAT OTHER OPTIONS HAVE YOU CONSIDERED, IF ANY?

Figuring out what the sticking point is and addressing it.

WHAT, IF ANY, CONCERNS DO YOU HAVE ABOUT MEDIATION?

We have always talked through our issues and are pretty much in agreement on the separation plan and asset division. A concern is disrupting this by introducing lawyers.

WHAT ARE YOUR EXPECTATIONS OF THE MEDIATION PROCESS?

Help guide us to a mutual agreed upon plan that allows us to move forward.

WHAT ARE YOUR EXPECTATIONS OF THE MEDIATOR?

Provide direction on steps needed, address questions, and bring back focus of what is needed to achieve a mutual agreed upon plan.

SELECT ALL THAT APPLY

I do not have any existing conditions

HAVE YOU BEEN ARRESTED OR INCARCERATED?

IS THERE A NO CONTACT ORDER OR PROTECTION ORDER IN PLACE?

BY CLICKING THE BUTTON BELOW, I CONFIRM THAT MY ANSWERS ARE TRUE AND ACCURATE

YES. I CONFIRM THAT ANSWERS ARE TRUE AND ACCURATE

SELECT THE APPLICABLE OPTION BELOW

I am using a touchscreen device to sign this document

Legal Name

Michael McFarlane

AGREEMENT TO MEDIATE

This Agreement to Mediate is an agreement bet

ween the undersigned (hereinafter referred to

as the "parties" or individually as a party)

and Holly Birdwell (hereinafter referred to

as the "Mediator") with Eagle River Mediation

(

hereinaf

ter refe

rred

to as "ERM") to enter into mediation. The pa

rties and the mediator agree to enter into me

diation under the following terms and conditi

ons:

MEDIATION

FEES

MEDIATION

FEES

a. The mediation

fee is $200.00

per hour.

b. Mediation

sessions are

2 hours.

c. Fees are split

equally between

the parties.

Mediation sessions are billed as
a block of time, whether used i
n part or whole.

All work performed by the med

iator and ERM staff outside o

f the mediation

session

is also billed at the same rate of $200.00 pe
r hour
.

Fees are billed in increments of one-tenth (

.1) of an hour, as outlined in the chart belo

Billable fees include,

but are not limited to,

the following:

a. Correspondence: Phon

e calls, emails, and te

xt messages

b. Preparation time b

efore and after media

tion sessions

c. Reviewing mate

rials provided by

the parties

d. Additional session time (

if your session extends past

the scheduled time)

e. Preparing and draf

ting summaries and ag

reements.

f. Correspondence with

the parties' counsel or

other advisors

g. Correspondence with ot

her professionals on beha

lf of the parties

h. Other tasks that are rea

sonably necessary to facili

tate an agreement

i. Re

searc

j. Other ag

reed-upon s

ervices

INCREMENTAL BIL

LING CHART

MINU

TES

BILL

ING

TIME

COS

0.00

13-

0.00

19-

0.00

25-

100

.00

31-

120

.00

37-

140.

43-

160.

49-

180.

55-

200.

FORM AND TIMIN

G OF PAYMENT

. Each session is paid for one session i

n advance, as outlined below.

First
Sess
ion

. Payment for the first session must be r

eceived in full by both parties before th

e first session is scheduled.

All Oth
er Sess
ions

. All other sessions must be paid i

n cash at the beginning of the sess

ion.

Form of
Paymen
t

. Payments must be made in cash at the begi

nning of each session. Payments made via cr

edit or debit card will incur a 3% fee. We

do not accept checks.

Drafting
Agreeme
nts

. The majority of the Agreement is drafted

outside of the session and is billed at t

he same rate outlined herein. Payment for

the agreement is due at the beginning of t

he Review Session (for in-person review se

ssions) or prior to the start of the sessi

on via online payment (for Zoom or phone r

eview sessions).

Invo
ices

. Invoices must be paid promptly upon recei

pt of the invoice otherwise, late fees, as

outlined herein, will be applied.

Additi
onal F
ees

. If the cardholder contests a credit card

charge, the contesting party will be respon

sible for paying the mediator and staff of

Eagle River Mediation a rate of $400.00 per

hour for time spent on the disputed charge

. Additionally, the contesting party will i

ncur a one-time disputed charge fee of $400

.00. If Eagle River Mediation permits you t

o write a check and the check is bounced, y

ou will incur a one-time fee of $50.00 and

must submit payment upon receipt of the inv

oice.

LATE PAYME

NT FEE

. The parties must maintain a zero balance at

all times. The parties agree and understand

that a recurring late fee of $50.00 will be a

pplied to balances after seven (7) days if pa

yment is not received; this is a recurring an

d compounding late fee every seven (7) days u

ntil payment is received.

PAYMENT ENFOR

CEMENT

. If ERM needs to enforce any provision outli

ned herein to collect fees or costs, the part

y(ies) are solely responsible for all legal f

ees, costs, and expenses outlined in 5.a. bel

ow. Additionally, the party(ies) will pay an

increased hourly rate of $400.00 per hour for

all work and time associated with collecting

fees.

a. Fees and costs include, but are not limi

ted to, attorney costs and fees, court cost

s and fees, collection costs and fees, the

time involved in drafting and filing docume

nts, travel time to and from the courthouse

, waiting time in the courthouse, receiving

and making telephone calls, drafting and r

eceiving letters or emails, correspondence

with the party(ies), correspondence with pr

ofessionals related to this matter, and all

other tasks associated with the collection

of fees.

OUTSTANDING PAYMENT F

OR SERVICES

If either party elects to terminate mediatio

n for any reason before executing the final a

greement, the parties are responsible for pay

ing all mediation fees up to that point, incl

uding any work completed on the final agreeme

nt.

Item - 17Apr2024 Intake Forms and Payment Image-1 2

AGREEMENT TO MEDIATE

EAGLE RIVER MEDIATION

MEDIATI

ROLE OF MED

IATOR

. The mediator's role, an expert in dispute r

esolution, is to act as a neutral facilitator

to support and guide the parties to a workab

le solution. The mediator will help reduce co

mmunication obstacles, identify and prioritiz

e issues, explore alternatives, and facilitat

e voluntary agreements resolving the dispute.

The mediator will not serve as an advocate f

or any party, make judgments about who is “ri

ght” or “wrong,” provide legal advice, or imp

ose any decisions on the parties. Instead, th

e mediator will ask questions to understand t

he issues, help the parties understand the ot

her person's point of view, discuss weaknesse

s in the parties' arguments, or make suggesti

ons to resolve the conflict.

CONFIDENT

IALITY

. All communications throughout the mediation

process, including pre-mediation conferences

, caucuses, phone calls, emails, and mediatio

n sessions, are strictly confidential. Neithe

r party shall reveal information from mediati

on in any court proceeding or any person who

is not a party to such discussions nor commun

ications. Persons present during the mediatio

n or persons involved in discussions or commu

nication regarding the mediation shall not re

veal such information in any court proceeding

or to any person not a party to such discuss

ions or communications. Individual conversati

ons with the parties are kept confidential be

tween the mediator and said party, and the me

diator is not responsible for disclosing info

rmation discussed in caucus or individual con

versations to the other party. Exceptions to

confidentiality:

a. All mediation partici

pants agree in writing, i

ncluding the mediator

b. A party to the m

ediation is in dange

r of bodily harm

c. A threat or statement of a

plan to inflict bodily injury o

r commit a crime of violence

d. Previously unreported

cases or suspicion of ch

ild or elder abuse

e. The mediator has evidence th

at a child has been abused, aban

doned, or neglected

f. The mediator has evidence that is reaso

nably believed that it must be disclosed in

order to prevent a party or person from co

mmitting a crime, concealing an ongoing cri

me, or posing a serious risk of bodily inju

ry or death to another person

g. In general, non-identi

fiable terms for training

or program evaluation

h. Within the confines of th

e company for administrative

and training purposes

JOINT & SEPARAT

E SESSIONS

. Both joint and private sessions may be used

by the mediator(s) to facilitate resolution.

Private sessions are strictly confidential u

nless the party agrees the mediator can share

information discussed during private session

s. Any party to a mediation may request a pri

vate meeting at any time.

The mediator will not correspond with either
party individually outside of a scheduled med
iation session.

CANCELATION, RESCHEDULE AND

NO-SHOW POLICY

. If it is necessary to cancel or reschedule

a mediation session, the party canceling or r

escheduling must provide

seven (7) business days advance notice to Eag
le River Mediation and the other party;

otherwise, the party canceling or rescheduli

ng is solely responsible for the entire sessi

on fee. Business hours are from 9:00 a.m. on

Monday until 1:00 p.m. on Friday. Each party

is responsible for knowing the date and time

of their scheduled sessions.

FULL DISCL

OSURE

. The parties understand full disclosure of a

ll relevant information is required to ensure

the success of mediation. Accordingly, the p

arties agree that they shall each fully and h

onestly disclose all relevant information and

documents, including information that would

otherwise be available through the discovery

process of litigation. Each participant agree

s to provide complete and relevant informatio

n and documents to each other and to the medi

ator.

NO RECOR

DING

. The mediation sessions are private and

may not b
e recorde
d

electronically or broadcast in any way witho

ut all participants, including the Mediators'

permission

Additionally, phone conversations between th

e mediator and each party are

private and may not be recorde
d without the mediator's conse
nt and permission

NON-PARTICIPATING

OBSERVERS

. Parties who wish to bring non-participating

observers must obtain approval from the medi

ator in advance. All observers will sign and

be governed by this Agreement to Mediate. In

addition to the mediator, Eagle River Mediati

on staff and interns may be present at mediat

ion sessions.

TESTIMONY AND

RECORDS

. The participants agree that they will not a

t any time before, during, or after mediation

call the mediator as a witness, subpoena or

demand the production of any records, notes,

files, work product or the like produced by t

he mediator in any legal or administrative pr

oceeding concerning the issues addressed in m

ediation or concerning any other issue. If a

participant seeks to do so, that participant

will indemnify the mediator as to all costs i

n connection therewith, including attorney’s

fees, and the party will compensate the media

tor for all time spent at the rate of $400.00

per hour.

If either party, or anyone on either party's

behalf, attempts, either successfully or unsu

ccessfully, to subpoena the mediator to any l

egal action, proceeding, or deposition (or in

any way involve the mediator in any other ty

pe of discovery or court proceeding), which i

n any way relates to the mediation, the said

party will pay the mediator $400.00 per hour

and will pay all costs and fees the mediator

incurs in the attempt to challenge such subpo

ena. These fees include but are not limited t

o attorney costs and fees, courts costs and f

ees, filing time, arguing and finalizing a Mo

tion or Order to Show Cause, travel time to a

nd from the courthouse, waiting time in the c

ourthouse, receiving and making telephone cal

ls or emails, and drafting and receiving lett

ers involving such matters. If the mediator’s

attempt to challenge is defeated, the party

will pay all of the mediator’s costs and fees

. The party will also pay the mediator $400.0

0 per hour for the mediator’s time related to

the matter, including but not limited to att

orney fees, court fees, travel time to and fr

om the courthouse, waiting in the courthouse,

testifying, conferencing, telephone calls, e

mails, letters, any other communication relat

ed to the matter, and all other time associat

ed with matter. The said party shall also pay

the mediator $400.00 per hour for time spent

on any appeal involved in such matters and p

ay all costs and fees associated with any app

eal.

RELEASE OF DOC

UMENTS

. This Agreement to Mediate and any written a

greements signed by the parties resulting fro

m this mediation may be used in subsequent re

levant proceedings.

10.

RECORD

. The mediator will destroy any parties' docu

ments within thirty 30 days of the final medi

ation session. The only document the mediator

will keep on file is a copy of the final agr

eement and a copy of this Agreement to Mediat

11.

CONSULTING WITH LEG

AL ADVISERS

. Any party not represented by a legal profes

sional or other appropriate professional advi

ser is advised to consult one as desired at a

ny time before, during, or after the mediatio

n session and throughout the mediation proces

s as each party desires. The parties understa

nd that the mediator is not an attorney, is n

ot giving legal advice, and is not analyzing

or protecting any party’s legal rights in the

mediation process.

12.

NO SUBSTANC

E USE

. The parties shall show up to mediation sess

ions in a sober state. There will be no alcoh

ol, tobacco, or substance use during any medi

ation sessions or immediately prior to a medi

ation session. If one or more parties show up

to the mediation session under the influence

of alcohol, prescription drugs, or illicit d

rugs, the mediation session will be canceled,

and the party under the influence will be re

sponsible for all session fees.

13.

TERMINA

TION

. Participation in mediation is voluntary, ex

cept when ordered by the Court. A party may w

ithdraw from or suspend the mediation by noti

fying the other party[ies] and the mediator b

y written notice. Additionally, the withdrawi

ng or suspending party shall inform the media

tor of the reason for withdrawing from or sus

pending the mediation. The parties understand

the mediator may suspend or terminate the me

diation if she feels the mediation will lead

to an unjust or unreasonable result; if the m

ediator determines that she can no longer eff

ectively perform her facilitative role; if th

e mediator feels that an impasse has been rea

ched; or if the parties do not follow the med

iation ground rules. If the mediator terminat

es a mediation session due to the parties’ un

willingness to follow the mediation ground ru

les, the parties are responsible for paying f

or the full session fee.

14.

MEDIATED AGRE

EMENTS

. All terms of a settlement are non-binding u

ntil they are put into a written agreement an

d signed by all parties, or, in the case of a

divorce, until an order is entered by the co

urt. Any mediated agreement may affect the le

gal rights of the parties. Each party is enco

uraged to consult with an attorney for legal

advice throughout the mediation process. Each

party is encouraged to have an attorney revi

ew any written agreement before signing it, a

nd when applicable, before filing it with the

court.

15.

EXCLUSIONS OF LIABILIT

Y AND INDEMNITY.

a. The mediator will not be liable to a par

ty for any act or omission by the mediator

in the performance or purported performance

of the mediator's obligations under this a

greement.

b. Each party indemnifies the mediator agai

nst all claims by that party or anyone clai

ming under or through that party, arising o

ut of or in any way referable to any act or

omission by the mediator in the performanc

e or purported performance of the mediator'

s obligations under this agreement.

16.

DISPUTE RESO

LUTION

If a dispute arises out of the mediation ses

sion between a party and the mediator that ca

nnot be resolved by direct negotiation betwee

n the party and the mediator, the dispute sha

ll be submitted to mediation with a mutually

agreed-upon mediator or one that the Court ha

s appointed.

I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE TO THE MEDIATION FEE TERMS OUTLINED HEREIN.

BY CLIKCING THIS BUTTON, I CONFIRM THAT I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE TO THE MEDIATION FEE TERMS OUTLINED HEREIN.

I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE TO THE PROVISIONS OUTLINED ABOVE.

BY CLICKING THIS BUTTON, I CONFIRM THAT I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE TO THE TERMS OUTLINED IN THE AGREEMENT TO MEDIATE.

SELECT THE APPLICABLE OPTION BELOW

I am using a touchscreen device to sign this document

MY SIGNATURE CONFIRMS THAT I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE MEDIATION FEE TERMS AND ALL TERMS IN THE AGREEMENT TO MEDIATE.

I CONFIRM THAT I HAVE CAREFULLY READ, UNDERSTAND AND AGREE TO THE MEDIATION FEE TERMS AND ALL TERMS IN THE AGREEMENT TO MEDIATE.

Mike McFarlane

mcfarlanemj@gmail.com

MEDIATION GROUND RULES

When people are emotional, the power of emotions overwhelms rationality, and Logic is suppressed. As a result, the IQ points needed to consider decisions are depleted temporarily. Therefore, be aware that you may misunderstand something if you become emotional about the conflict.

Be respectful. Listen respectfully and sincerely. Try to understand the other person's needs and interests.
Do not interrupt when the other party is speaking. Instead, make a note or what you would like to say and wait your turn to speak.
Do not blame, attack, call names, or engage in put-downs. Do not use profanity. Use non-inflammatory words/language.
Do not make assumptions about what the other party thinks, feels, or wants. Do not speak for the other party.
Ask questions for the purpose of gaining clarity and understanding. Work to understand the other party’s perspective without being judgmental about the person or the message.
Speak for yourself; make “I” statements rather than “You” statements.
Use the other party’s first name when speaking about the other party. Avoid “he” or “she.”
Focus on solutions instead of problems. Raise your concerns with a constructive suggestion as to how it might be resolved.
Focus on future actions rather than past events.
Be open to creative solutions.
No use of cell phones during the session. Cell phones must be powered off during the session.
Children are not allowed in mediation.
No chewing tobacco, alcohol, or drug use during the mediation session.
Firearms are not allowed in the mediation session.
The mediator must approve the presence of additional parties in the mediation session.

THE MEDIATOR IS IMPARTIAL AND FOCUSED ON HELPING YOU REACH A SOLUTION.

I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE THAT I WILL ADHERE THE MEDIATION GROUND RULES.

BY CLICKING THIS BUTTON, I CONFIRM THAT I HAVE CAREFULLY READ, UNDERSTAND, AND AGREE THAT I WILL ADHERE TO THE MEDIATION GROUND RULES.

Invoice ID

# INV-QZE7ZZ

MEDIATION SESSION PAYMENT

EAGLE RIVER MEDIATION

LEGAL NAME

Mike McFarlane

Phone Number

(206) 850-1767

mcfarlanemj@gmail.com

ADDRESS

130 W Horizon Dr

BOISE, Idaho, 83702

IS YOUR SESSION SCHEDULED OR IS SCHEDULING PENDING?

Pending

BY CHECKING THE BOX BELOW YOU ARE AUTHORIZING EAGLE RIVER MEDIATION TO PROCESS PAYMENT ON YOUR CREDIT

I hereby authorize EAGLE RIVER MEDIATION to charge my credit card for mediation services.

MEDIATION SESSION

Payer Information

Mike McFarlane

Transaction ID

22900686D2479343L

Description	Amount
ONE MEDIATION SESSION $200.00 x 1	$200.00

$200.00

PAYMENT RECEIVED:

Wednesday, November 20, 2024

Your payment of $160.00 covers your share (which is 50%) of the total mediation fee for one (1) mediation session.

**The fee is $160.00 per hour. Sessions are 2 hours. Each party is responsible for 50% of the fees. Therefore, each party will pay for 1 hour of mediation.**

NonProfit Donation Consent Template

Insurance Waiver Template

Rent Ledger Template

Professional Medical Release Template

Hospital Discharge Template

General Release of Liability Form