SECTION A:
This section must be completed by all those seeking
PRACTITIONER MEMBERSHIP
MEDIATOR, OTHER ADR and/or COLLABORATIVE

Name (first, middle, last)

Firm Name (if applicable)

Street Address

City, State, ZIP

County

Office Phone
Home Phone (not for publication)

Fax

Email

Please provide the following professional designation(s) (check all that apply):

PhD, PsyD , EdD, JD, Esq., EdD, MSW, LCSW ,

LMFT , LPC , MA , MBA , MS , CPA, CFP, CDFP ,

Other (Specify)

Educational Qualifications: All Practitioner Members must have a postgraduate or professional degree in a field related to divorce mediation and/or family dispute resolution.  Please provide the following information:

Name of Institution

Degree
Month/Year when degree received (xx/xxxx)

Professional Qualifications: Proposed member must be one of the following: mediator, collaborative divorce lawyer, other lawyer, financial professional, mental health professional, clergy, judge, Family Relations Officer, guardian ad litem, attorney for the minor child, or educator; and must be in good standing with the Connecticut agency or organization that licenses or regulates said profession. Please provide the following information:

Name of Agency or Organization

Year admitted/licensed/certified Degree

Insurance and Continuing Education Requirements: Please check both boxes below to confirm that you meet CCDM’s Insurance and Continuing Educational requirements.

All Practitioner Members must carry professional liability insurance that covers the specific ADR activities carried on by the member or be otherwise indemnified from said activities.

A Practitioner Member shall complete ten (10) hours of continuing education per year in areas related to mediation or the member’s specific ADR field by attending conference workshops and institutes; advanced training courses approved by the Association for Conflict Resolution or programs sponsored by relevant professional and mediation organizations.

Thank you for completing Section A of your application.

Your Next Steps:

To Apply for Practitioner Membership – Mediator:
Complete Sections B & E and/or

To Apply for Practitioner Membership – Other ADR:
Complete Sections C & E and/or

To Apply for Practitioner Membership – Collaborative:

Complete Sections D & E & the Minimum Standards for Collaborative Practitioners form

Jump to Section B | Jump to Section C | Jump to Section D

Section B:

This section must be completed by all those seeking
PRACTITIONER MEMBERSHIP - MEDIATOR

Practitioner Member – Mediators must have completed an ACR-approved or AFM-approved, 40-hour course specific to divorce mediation, which shall include training in domestic violence issues. (The Academy of Family Mediators (AFM) has merged into the Association for Conflict Resolution (ACR).)  If you have taken a 40-hour training course that was not ACR approved, you qualify for Practitioner Membership only if you first became a Practitioner member before January 1, 2005.

IMPORTANT NOTE: Before continuing on with your membership application, you must first confirm that your course is ACR-approved in order to meet CCDM’s membership requirements for training.   If your training is not listed, please contact CCDM at 888-236-2236 before completing your application. Otherwise, please provide the information requested below.

Training Details

Yes, my training is ACR-approved.

Trainer
Location of training (state)

Year(s) in which I took the training

Experience Requirements: Practitioner Member – Mediators must have a minimum of two (2) mediations prior to membership and two (2) mediations per year thereafter.

Standards of Practice: Practitioner Member – Mediators shall abide by the CCDM Standards on Mediation and the Unauthorized Practice of Law and the ACR Standards of Practice for Family and Divorce Mediation.

“I have read and understand the Connecticut Council for Divorce Mediation Standards on Mediation and the Unauthorized Practice of Law and the Association for Conflict Resolution Standards of Practice for Family and Divorce Mediation.”

Name in lieu of signature

Skip to Section E to complete your application (or complete Section C to apply for Other ADR or Section D to apply for Collaborative Practitioner membership.

SECTION C:
This section must be completed by all those seeking
PRACTITIONER MEMBERSHIP – OTHER ADR

Training Requirements: Practitioner Members – Other ADR must have completed forty (40) total hours of ADR training, at least twenty (20) hours of which must be in family dispute resolution, and the remainder of which may be in substantive areas relating to the member’s specific ADR field.

Training Details: Yes, I have completed the above-mentioned training and provided details below.

First Trainer

Location(s) (i.e., state)

Number of hours Year

Second Trainer

Location(s) (i.e., state)

Number of hours Year

Third Trainer

Location(s) (i.e., state)

Number of hours Year

Fourth Trainer

Location(s) (i.e., state)

Number of hours Year

Experience Requirements: Practitioner Members – Other ADR must have a minimum of two (2) matters in the member’s specific ADR field prior to membership and two (2) matters per year thereafter. 

Please describe the specific ADR field:

Skip to Section E to complete your application (or continue to Section D to apply for Collaborative Practitioner membership.

SECTION D:

This section must be completed by all those seeking
PRACTITIONER MEMBERSHIP – COLLABORATIVE

Step 1. Training Requirements:Practitioner Members – Collaborative must satisfy CCDM’s Minimum Standards for Collaborative Practitioners.  All applicants seeking Practitioner membership as a collaborative professional must complete the training information for his/her profession (legal, mental health, financial) on the Minimum Standards form. Click to download a PDF version of this form.

I have completed Minimum Standards for Collaborative Practitioners form and attached it to my application.

Step 2. Experience Requirements: Practitioner Members – Collaborative must have a minimum of two (2) collaborative divorce cases in the member’s profession (legal, mental health or financial) prior to membership and two (2) collaborative divorce cases per year thereafter.

Step 3. Skip to Section E to complete your application (reminder: you must also complete and submit the Minimum Standards for Collaborative Practitioners form.

SECTION E:
This section must be completed by all those seeking
PRACTITIONER MEMBERSHIP
MEDIATOR, OTHER ADR and/or COLLABORATIVE

Before completing this final Section of your application, please take a moment to thoroughly review your application to ensure that all required information has been provided.

Step 1. Certification of Qualifications*: I hereby certify that I meet the qualifications stated above for membership in the Connecticut Council for Divorce Mediation and Collaborative Practice as a (check any/all categories that apply):

Practitioner Member – Mediator
Practitioner Member – Other ADR
Practitioner Member – Collaborative (please check any/all professions that apply) Lawyer Mental Health Professional Financial Professional

Name in lieu of signature

Date (xx/xx/xxxx)

*A proposed member may petition the Membership Committee of the Connecticut Council for Divorce Mediation and Collaborative Practice for a waiver of any of the above qualifications, if said request is for good cause shown and the proposed member’s training and mediation experience and/or ADR experience is extensive and provides the proposed member with qualifications equivalent to or greater than those set forth above. For more information, contact CCDM at 888-236-2236.

Step 2. Optional Membership Benefits

CCDM ListServ
All Practitioner Members are invited to participate in CCDM’s ListServ at no charge. Note, you must provide an email address in Section A of your application to be added to our online community. Check box to be added.

All Practitioner Members have the option to include a web site link with their listing in CCDM’s online Membership Directory for an additional $50 fee. Check box to list web site and print URL below:
Web address (URL)

Step 3. Application Submission Instructions: First, indicate the amount you are paying:

$150 Practitioner Membership Fee without web site link

$200 Practitioner Membership Fee with web site link

Then you can click "Submit" and you will be directed to a page where you can either a) pay online using Pay Pal (no pay Pal account needed) or b) opt to mail your check.

WE RECOMMEND YOU PRINT THIS PAGE BEFORE SUBMITTING TO PRINT A COPY OF YOUR COMPLETED APPLICATION. ONCE YOU HAVE CHECKED IT CAREFULLY FOR ACCURACY AND COMPLETENESS, PLEASE CERTIFY THE FOLLOWING. (You must check the following box before submitting the form:)

You must chedck this box before submitting. I have checked this form for accuracy and completeness and, if desired, I have printed the page for my records.

Send to CCDM