Mediation Disclosure and Consent Form
The Wayne County Dispute Resolution Center offers voluntary mediation under the Michigan Dispute Resolution Act, MCL 691.1551 et seq.

The role of the mediator in mediation is to help the parties talk with one another, so that parties can understand one another. If an agreement can be reached, the mediator will put that agreement in writing and have the parties sign it. A written and signed agreement is enforceable in the same manner as any other written contract. BY SIGNING THIS DOCUMENT BELOW, I ACKNOWLEDGE THAT I HAVE READ THIS ENTIRE DOCUMENT AND I UNDERSTAND IT. IN ADDITION, MY E-SIGNATURE BELOW SHOWS THAT I HAVE AGREED TO TRY TO RESOLVE THIS CASE THROUGH MEDIATION AND IF AN AGREEMENT IS REACHED, I WILL ACT IN GOOD FAITH TO UPHOLD AND SUPPORT THAT AGREEMENT.


I understand that:

1)     My participation in mediation is voluntary.
2)     I am NOT required to reach an agreement during mediation.
3)     If a settlement is not reached, I do NOT give up my right to go to court OR to use any
        other method of alternative dispute resolution.
4)     No one involved in the mediation will be bound by anything said or done in mediation
         unless a settlement agreement is reached by the parties.
5)     A mediated agreement is legally enforceable.


I understand that:

1)      Mediators are completely neutral.
2)      Mediators do NOT act as attorneys or advocates for any party in mediation. I have the
          right to speak to an attorney if I have a question about legal issues.
3)      Mediators are NOT judges; they will NOT decide who is right or wrong or who wins
          or loses this case.


I understand that:

1)      Statements, both verbal and nonverbal, made during mediation are confidential, not
          subject to discovery and cannot be used in a subsequent proceeding except in the
          following circumstances:
                           a.)     All mediation parties agree in writing to disclose.
                           b.)     The statement is made to WCDRC staff for administrative purposes.
                           c.)     The statement is a threat or a plan to inflict bodily injury or commit a
                           d.)     The statement is used to plan a crime, attempt to commit a crime, or to
                                     conceal a crime.
                           e.)     The statement involves a new allegation of abuse or neglect of a child,
                                     a protected individual, or a vulnerable adult. Mandatory reporters are
                                     required by law to report any allegations of child abuse, elder abuse,
                                     and/or abuse of a protected individual to the appropriate authorities.
2)      By its nature, this form is not intended to be confidential.
3)      Any mediation agreement reached during mediation may be released to the referral
          sources with written consent from the parties.
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E-signature *
Name *
Date *
WCDRC Case ID # (if provided)
Please refer to the email for this number.
Consent to Observer/Co-Mediator *
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