Mediation Session Discharge Form
Complete this form to document the conclusion and outcomes of your mediation session.
Session Date and Time
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Mediator's Full Name
*
First Name
Last Name
Participant 1 Full Name
*
First Name
Last Name
Participant 2 Full Name (if applicable)
First Name
Last Name
Session Location
*
Issues Discussed During the Session
*
Session Outcome
*
Full Agreement Reached
Partial Agreement Reached
No Agreement Reached
Session Postponed
Other
Summary of Agreements or Actions to be Taken
Participant Feedback on the Mediation Process
How satisfied are you with the mediation session?
1
2
3
4
5
Participant Signature
*
Submit Discharge Form
Submit Discharge Form
Should be Empty: