Neutral Third‑Party Mediation Protocol — Interactive Session Record

Purpose and use

This interactive protocol guides a neutral facilitator through intake, mediation, note-taking, and follow-up. Use it during or immediately after sessions to capture accurate, neutral records and agreed actions. The form is structured to protect dignity, identify safety concerns, and support clear follow-up.

Confidentiality template (read aloud or share before starting)

We will treat what is shared in this mediation as confidential between the parties and the neutral facilitator. Confidentiality means we will not disclose mediation communications to others except when one of the following applies: there is an immediate risk of harm to someone; information reveals possible illegal activity that must be reported; there are mandatory organizational, regulatory, or legal reporting requirements; or a written agreement specifies disclosures. If we must break confidentiality for safety or legal reasons, we will explain why and, when possible, give advance notice. By checking the confirmation box below you and the other party acknowledge you understand these terms.

How to use this form

Complete the intake fields before the mediation (or at the session start). Use the staged agenda fields during the session to capture perspectives, interests, options, and the agreement. Complete the follow-up and escalation fields at the end of the session. If escalation criteria are met, follow your organization’s formal procedures.