Renewal Membership Forms

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 with Website Listing A benefit we offer for MCI Referral List 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 included in your selection above. (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 web site

Please select county or counties that are within 5 miles to your office address(es)

2. Please submit documentation for MCI’’s ANNUAL CONTINUING EDUCATION REQUIREMENT Regular Member (3 credits), Associate (3 credits), and Referral Applicants (6 credits).

3. 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.

4. In the past year, have there been any changes in your status with respect to verification, licensure, or required memberships in organizations related to your professional endeavors?

5. REGULAR and REFERRAL LIST MEMBERSHIP APPLICANT: Provide supporting documentation for continuing education requirement and a copy of your current licenses, certification, or membership card by email or upload.

6. 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

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

8. 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.

YESNO
9. 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.