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Title *
First Name *
Surname *
Company Name (if relevant) *
Home Telephone *
Home Email *
Home Address *
Solicitor Name*
Name of Firm *
Solicitor DX*
Solicitor Telephone *
Solicitor Fax
Solicitor Email *
Solicitor Address *
Reference *
Please provide a brief description of the nature of the dispute: *
What is the amount in dispute? *
Would you describe this as a complex case? * YesNo
Has a Claim been issued? * YesNo
Is this referral made by the Court as part of case management? * YesNo
Have all parties agreed to proceed with mediation (where not ordered by the Court)? If not, whose consent is outstanding? *
Are there any dates that should be avoided for the mediation? if so, please list them: *
Where is it proposed for mediation to take place? *
Please confirm who will be attending (e.g Solicitors, client and other professional advisors): *
How did you hear about Becket Mediation? *