CAUSE NO. _____
IN THE MATTER OF THE § IN THE DISTRICT COURT
MARRIAGE OF §
§ ____COUNTY, TEXAS
_______________________ §
and §
_______________________ § _____th JUDICIAL DISTRICT
AGREED ORDER OF REFERRAL FOR MEDIATION
This case is appropriate for mediation in accordance with sections 6.602 and 153.0071 of the Texas
Family Code.
__ MEDIATOR’S NAME __is selected as the mediator in the above case, and all counsel and all pro se
parties agree to contact the mediator to arrange the logistics of mediation.
The mediator’s address is __ , phone number is __, fax number is __ and email address is __.
This mediation is a mandatory settlement conference, conducted with the assistance of the mediator. A
mediated settlement agreement can be made binding on the written agreement of the parties. Mediation is
private, confidential and privileged, except as provided by applicable law. After mediation the Court will be
advised by the mediator, the parties and counsel only that the case did or did not settle. The mediator shall not
be a witness and the mediator’s records may not be subpoenaed or used as evidence. No subpoenas, citations,
writs, or other process shall be served at or near the location of any mediation session on any person entering,
leaving or attending any mediation session.
The fee for the mediation is determined by the mediator and paid ____% by husband/father, and ____% by
wife/mother, paid by the parties directly to the mediator in advance of the mediation by cash, cashier’s check,
debit/credit card or attorney’s check. No personal checks are accepted.
The mediator’s fee for 4 hours is $___ per party. If the mediation goes beyond 4 hours then the mediator
charges each party an additional $___ per hour due at the time of the mediation. If more than one session is
necessary, the parties will pay the additional fees for the second session.
The mediator charges a $___ non-refundable scheduling fee (via credit/debit card, attorney check or
money order delivered to his/her office) due before the mediation will be placed on his/her mediation calendar.
Every participant is bound by the rules for family law mediation and each party agrees to timely complete
and supply all information requested by the mediator 72 hours prior to the actual mediation.
It is agreed that all parties, the Amicus Attorney (if any), and at least one attorney for each party
represented by an attorney, shall be present during the entire mediation process. It is understood that no party
may leave the mediation site without the express consent of the mediator.
All pro se Parties, attorneys and the Amicus Attorney (if any) are all to mediate this matter on
___________________________________ (or) before the trial date of ________________________________.
All parties, counsel and the Amicus Attorney (if any) agree to appear as directed by the mediator. Referral
to mediation is not a substitute for trial.
Signed _____________, 20__.
_______________________________ _______________________________
Petitioner/Petitioner’s Attorney Respondent/Respondent’s Attorney