Family Mediation Referral

Please note – information on this form will be shared with your (ex) partner unless you specifically indicate otherwise.

1. Your personal details

2. Confidentiality

Before mediation can proceed we usually arrange to share the contents of this Referral Form with your partner/former partner. Please tick this box if you would prefer we did not do so at this stage.

Please tick this box if you would like us to keep your private address or telephone number confidential from your partner/former partner.

3. Stage of Proceedings

Are you consulting a solicitor? *
YesNo

If so, please give us his/her name, address and telephone number

Are you currently involved in divorce or other family or children proceedings? *
YesNo

If so, what stage have they reached?

Have you and/or your partner/former partner had any form of relevant counselling/therapy or involved any other professionals (e.g. Relate, Social Services)? *
YesNo

If yes, please give details of the other professionals involved

Where did you hear about mediation? *

4. Contact Information

Home Address *

Work Address

Work Email

How is it most appropriate to contact you? *

5. Relationships

Are you seeking? *
Permanent separationDivorce

Do you think your partner/former partner wants? *
Permanent separationDivorce

Have you made attempts at reconciliation? *
YesNo

If either of you was married previously, please give brief details

Have you remarried? *
YesNo

Are you cohabiting? *
YesNo

IMPORTANT:

Are there any issues of protection, violence or safety which we may need to address?
YesNoNot sure

Would you like further information on this?
YesNoNot sure

Normally mediation takes place with both of you in the room at the same time. Are there any reasons why you would wish to start the first session separately?
YesNoNot sure

6. Children and other Dependants

With whom are the children living?

Please outline the current arrangements for the children

If you are separated from the other parent, are the children in contact with both parents, or with any other persons?

To what extent are the children aware of the situation between you?

What are the arrangements for financial support in relation to any of the children?

Child Support Agency involved?
YesNoNot sure

Child Support Agency Assessment made?
YesNoNot sure

Court order for maintenance?
YesNoNot sure

Voluntary maintenance arrangement?
YesNoNot sure

Other?

Is financial support in relation to any of the children actually being paid?
YesNoNot sure

If so, how much and how often?

Do you have parental responsibility for your children?
YesNoNot sure

Is this an issue between you and your partner/former partner?
YesNoNot sure

7. Preliminary Financial Outline

If financial matters are to be considered, a more detailed questionnaire will be supplied.

Property

Employment

What is your occupation? *

Current gross salary or earnings from work (please bring documentary confirmation with you to your first appointment with a mediator) *

Do you have any other sources of income? *
YesNo

If yes, please provide details and amount

8. Outline of issues you want to resolve

Property and Finance *
YesNoNot sure

Children *
YesNoNot sure

Relationship Breakdown Issues *
YesNoNot sure

Divorce and/or Separation *
YesNoNot sure

Emotional/Communications issues *
YesNoNot sure

Other?

9. Your reasons for coming to mediation

Please indicate what issues you feel need to be considered and what your aims are in coming to mediation. We appreciate that you may need to know more from the mediator/s, but it would help to have some preliminary idea of what you hope to achieve. Please do not provide or send copies of correspondence that cannot be mentioned in joint discussions with you both. Mediators cannot receive information that is confidential to one of you (except a private address or telephone number you want to keep confidential from a partner/former partner)