Mid Mediation Referral Form

MiD Mediation Referral Form

Today’s Date:______

Please fill in as much as you can and return the form by email or post, we will then contact you to discuss making your initial appointment with one of our experienced mediators.

Your details:Other Party details:

Name:Name:

Address:Address:

Postcode:Postcode:

Local Authority:Local Authority:

Tel – Res:Tel – Res:

Tel – Bus:Tel – Bus:

Tel – Mob:Tel – Mob:

E-Mail Address:E-Mail Address:

Occupation:Occupation:

D.O.B:D.O.B:

N.I.N:N.I.N:

Would you like us to not disclose address to (ex) Partner?Yes/No/Don’t mind

Are there any domestic violence concerns:Yes / No

Please comment with brief details:

Details of Children involved:

Name M/F D.O.B.AgeLiving with

What issues would you like mediation for: (Please tick what applies)

All Issues [ ] Children Only [ ] Property and Finance Only[ ] Other (please specify)

Solicitor Details:(if known)

Solicitor: Solicitor:

Address:Address:

Postcode:Postcode:

Telephone:Telephone:

Do you or the other party have any additional needs? e.g. interpreter

Current situation: Please complete where relevant

Married [ ]Not married [ ] Married/Living together since:______Date of separation:______

Date of divorce petition:______Petitioner?______Date decree nisi:______

Date decree absolute:______Last court hearing date:______Future court dates:______

If appropriate, specify how MID should approach Second Party

1. MID write to Second Party asking Second Party to contact MID for individual/joint appointment [ ]

2. Do not contact Second Party prior to Client’s individual meeting with a MID mediator [ ]

3. Other (please specify) [ ]

We offer appointments on Monday – Friday between the hours of 8.30am to 5pm

Your availability for appointments:Other Party’s availability for appointments:

Further Comments:

How did you find out about MiD? Did you find us via google, facebook, or other websites such as Family Mediation council or NFM. Did you see our leaflets in libraries, community centres, citizen’s advice bureaus or elsewhere? Did a solicitor or friend refer you to us?

Signature of Client: ______Date: ______

MiD Mediation & Counselling Ltd.

114 High Street, Hampton Hill, TW12 1NT Tel: 0208 8916860

Updated March 2016