Mediating Divorce Agreement

When a marriage or a couple's relationship is coming to an end, the willingness to cooperate with the other party often does not come easily. Sometimes one party is of the opinion that the other is responsible for the prevailing loss and accompanying pain. The situation is more difficult of resolution when the custody of children is an issue.

The purpose of this instrument is to assist you in realizing the extent to which you are ready to pursue the mediation process as a means of arranging how you are to spend your time with your child(ren), and further, how you can best exercise your responsibilities. It is most important that you consider carefully your thinking and feelings about each item before responding. After you have completed the items, we will discuss the implications of your responses and take it from there.

The scale of 1 to 5 represents a range of thoughts and feelings. Number 1 indicates that you are not ready or have strong negative thoughts or feelings about an issue. (These can be described at the end of the questionnaire.) Progressively up to number 5, your thoughts and feelings are less negative and less reluctant and a 5 indicates that you are quite positive about the item, that, in fact, you're ready and willing to discuss the matter toward a viable solution.

Name__________________________________________ Date _____________

(Circle the number closest to how you think and feel right now.)

No Yes

1. Do I really want to resolve the issues before us equitably? 1 2 3 4 5

2. Am I willing to put aside my anger and deal with the issues in a rational manner? 1 2 3 4 5

3. Am I willing to make some compromises and let go of some of my hopes, fears and disappointments? 1 2 3 4 5

4. Do I value the importance of the child(ren)'s relationship with their other parent? 1 2 3 4 5

5. Am I willing to work towards our most constructive and fairest agreement? 1 2 3 4 5

6. In regards to parenting, am I willing to consider the child(ren)'s needs above my own? 1 2 3 4 5

7. Can I share the children and be separate from them when they are with the other parent? 1 2 3 4 5

8. Can I share control, authority and decision-making regarding the children? 1 2 3 4 5

9. Can I keep the children protected from my angry or hurt feelings and complaints about the other parent? 1 2 3 4 5

10. Am I openly supportive of the child(ren)'s relationship with their other parent? 1 2 3 4 5

11. Do I really believe that it is okay with me for them to have a full relationship with that parent? 1 2 3 4 5

12. Can I stick to the issues regarding the child(ren) when we must communicate about them? 1 2 3 4 5

13. Can I accept the differences that exist in the other parent's style of parenting? 1 2 3 4 5

14. Am I willing to work with the other parent to find a way to handle the fact that we have these differences? 1 2 3 4 5

15. Am I willing to have open and forthright communication with the other parent in order

to communicate important events/information? 1 2 3 4 5

16. Am I willing that the child(ren) spend time, on an overnight basis, with their other parent? 1 2 3 4 5

17. Am I willing that the child(ren) spend time, on an overnight basis, with their other parent's parents (i.e., their grandparents)? 1 2 3 4 5

18. Can I accept the possibility that at some point in the future my child(ren) may well have a step- mother or stepfather? 1 2 3 4 5

19. Where I have indicated a 1 or 2 (negative) level of thoughts or feelings, am I prepared to discuss what my needs and interests are around that issue? 1 2 3 4 5

COMMENTS: _______________________________________________________

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

*Adapted by Eugene mediator diator Kathleen O'Connell Corcoran, MS, from an instrument prepared by Portland mediator Lois Gold, ACSW, Ray Lowe, EdD of the University of Oregon, Department of Counseling and Educational Psychology.