PLEASE COMPLETE THE FOLLOWING FORM ON BEHALF
OF YOUR CLIENT AND RETURN TO THE RELEVANT MEDIATION SERVICE PRIOR
TO YOUR CLIENT'S FIRST APPOINTMENT. IT IS ESSENTIAL THAT YOUR CLIENT
SPEAKS DIRECTLY WITH THE MEDIATION SERVICE TO ARRANGE THE APPOINTMENT.
YOUR DETAILS
Your firm's name
Address
DX Number
Telephone No
Fax No
Your reference
Your email
YOUR CLIENT'S DETAILS
Name of Client
Address
Telephone No
Date of birth
National Insurance No
Date of marriage to other party, if married
Is address confidential from other party?
Yes
No
Is client willing for partner to be contacted?
Yes
No
FORMER PARTNER'S DETAILS
Name
Address
Telephone No
Solicitor's Name
Address
DX Number
Telephone No
Fax No
Reference
Email
CHILDREN'S DETAILS - PLEASE SPECIFY FOR EACH
CHILD NAME, AGE & DATE OF BIRTH, WHETHER MALE/FEMALE AND WHOM
LIVING WITH
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
DETAILS FOR MEDIATION
Is this referral under Legal Services Funding?
Yes
No
Have any Court proceedings commenced?
Yes
No
If so, what proceedings, in which Court and what stage
has been reached?
Date of Separation
Date of Decree Nisi
Date of Decree Absolute
Type of mediation sought - please indicate whether in
respect of Children, Property or Both
Has there been any history (alleged or actual) of violence,
harassment, intimidation or child protection concerns?