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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

    3. Stage of Proceedings

    4. Contact Information

    5. Relationships


    6. Children and other Dependants

    7. Preliminary Financial Outline

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



    8. Outline of issues you want to resolve

    9. Your reasons for coming to mediation


    Becket Chambers takes the protection of your personal information very seriously. All information you supply to us within this referral form is only shared with those members of staff and administration who need to have it to work on your case.

    Once you become a client, this form will become part of your file and will be kept both in a file and electronically with your case papers. These will be destroyed once your case is closed in accordance with our Retention Policy.

    If you do not become a client, this form will be destroyed in accordance with out Retention Policy.

    If you have any concerns about the safety of your personal information, please see a copy of our Privacy Notice, both on-line or by request from the Chambers.



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