New Membership Registration

Please select a payment option. If you choose the Check option or the PayPal Invoice option, you can ignore the PayPal link after your form submission.

REFERRAL LIST APPLICANTS ONLY. A benefit we offer for MCI Referral Members is to post your website address with your MCI Referral Directory listing. To have your website link posted with your MCI Referral member listing, MCI requires that you provide a link back to the MCI website on your website at all times. The fee for posting your website on the MCI website is a $25.00 annual fee. (Please note, that there will be no pro-ration of this fee and renewal of this fee will coincide annually with your Referral membership renewal.)

1.Please provide the following information. Referral members please provide information as you want it to appear on the website

(Referral members only provide additional addresses where service provided)
Please select county or counties that are accessible within 5 miles to your office address(es)

2. Please describe how you completed at least forty (40) hours of family mediation training approved by the Academy of Family Mediators or the Association of Family and Conciliation Courts. Please provide a certificate of completion or equivalent documentation by email attachment or upload.

3. Please describe how you completed two (2) hours of mediation training on domestic violence. Please provide a certificate of completion or equivalent documentation by email attachment or upload.

4. REQUIRED FOR REFERRAL APPLICANTS ONLY: Please provide the following information for your Mediator Professional Liability Insurance. Please email or upload 1) a copy of the current declarations page from your policy, and (2) any additional documentation that is necessary to show that your policy expressly covers you for mediation and the effective dates of the policy. (Please note that some therapists’ and counselors’ policies do not expressly cover mediation and will not satisfy this requirement.) You are responsible for providing updated policy information should your policy expire prior to the term of your membership.

5. Please describe how you have completed the mediation experience requirement. Regular membership applicants must have completed three (3) hours of mediation experience and Referral Membership Applicants must have completed five (5) family meditations.

6. Please describe your educational background (Law? Mental health? Financial?) and what degree(s) you hold. All applicants must have at least a Bachelor’s degree and provide verification of the degree by email attachment or upload.

7. Please describe the nature of your current professional practice.

8. Please describe your professional background.

YESNO
Do any of the professions in which you practice require licensure, certification, or membership in an association or organization?
If yes, do you hold the required license, certificate, or membership and are a member in good standing?

Please describe the requirement and provide a copy of your current licenses, certification, or membership card by email or regular mail.

10. Are you willing to be included on a mediation Council of Illinois list of pro-Bono mediators? If yes please list the how many you are willing to do next year if not please leave field blank.

please list the number of pro_Bono referrals you would be willing to accept

11. REQUIRED FOR ALL MEMBERS. Check all types of family mediation services offered.

12. What type of mediation services do you provide other than family mediation? Please describe your non-family mediation services and include your experience in terms of training, number of mediation's conducted, years of experience, etc.

13. Please list any languages in addition to English in which you conduct mediations:

YESNO
14. Your name will be automatically included in MCI mailings and online communications. If you do not want to be included in these lists please designate.

REQUIRED FOR REFERRAL APPLICANTS ONLY:

Please Type Full Name

Submit Below. Please review membership fee amount before submitting if using paypal on the next page.