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Mediation Referral Form


Relating to Children

Property & Finance

Both

Have you made any allegations of domestic violence against the other?

Any other issues you wish us to be aware of ?

REFERRAL TYPE:  
You/Party A Details Other Person/Party B Details
Relationship to you?


eg. Husband, wife, ex-partner, son etc
Name: (required)

Name:

Address: (required)

Address:

Email: (required)

Email:

Telephone: (required)


Telephone:

Mobile:


Mobile:

Solicitor details: (required)

Solicitor details:

Do you or other party have any special needs?

Will you or other party require an interpreter? *

 *If yes, language?

Do you or other party require disabled access?

Do you think you or the other person might be eligible for legal aid?

Is the other party aware of the referral to mediation?

Do you wish us to contact them at this stage?

Where would you prefer to meet with us?

For security purposes please answer this simple question:
What is 2 + 2?