Becket Mediation

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 *

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? *

Civil and Commercial Mediation Referral Form