Step 1. Please provide all contact information requested below:

Name (first, middle, last)

Firm Name (if applicable)

Street Address

City, State, ZIP

County

Office Phone
Home Phone (not for publication)

Fax

Email

Step 2:  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)

Step 3. Please review the following insurance and continuing education 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.

Step 4: Please review the following experience and standards requirements:

Practitioner Membership - Mediator: a) Must have a minimum of two (2) mediations in the last twelve (12) months and b) 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.

Practitioner Membership - Other ADR: Must have a minimum of two (2) matters in the member’s specific ADR field in the last twelve (12) months.

Practitioner Membership - Collaborative: a) Must have a minimum of two (2) collaborative divorce cases in the member’s profession (legal, mental health or financial) in the last twelve (12) months and b) Must continue to meet CCDM’s Minimum Standards for Collaborative Practitioners for his/her specific collaborative profession.

Step 5. 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 6. 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 STEP 1 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 provide URL below:
Web address (URL)

Step 7. 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