Family Mediation Referral Form

Please complete all possible fields before submitting this form.

 

Referrer Name Referrer Email

Client 1

Name Date of Birth Address Tel. Home Tel. Mobile Tel. Work E-mail Is the above information confidential? Availability Solicitor's Details Tel No E-mail Fax Is your Client assisted under the Legal Help and Help at Court Scheme? If Mediation does not succeed is it the intention that your Client is seeling a Public Funding Certificate?

Client 2

Name Date of Birth Address Tel. Home Tel. Mobile Tel. Work E-mail Is the above information confidential? Availability Solicitor's Details Tel No E-mail Fax Is your Client assisted under the Legal Help and Help at Court Scheme? Is the Solicitor aware of the referral?

Do you need a MIAM? Urgent Special Access / Needs Intake Appointment Domestic Violence screening has been undertaken and there are no concerns? If Yes Child Protection screening has been undertaken and there are no concerns? If Yes Are any outside professional agencies involved? If Yes Are there current or imminent Court Proceedings? If Yes Date of Separation Date and Location of Marriage / Civil Partnership / Cohabitation

Names and Dates of birth of Children

1. 2. 3. 4. 5. With whom they are resident

Mediation required for:

1. Divorce/Dissolution of a Civil Partnership 2. Separation 3. Financial 4. Children Notes

Please print a version of this form for your own records.