Family Mediation South East

Solicitor/CAB (other Agencies) referral for first appointment with a Mediator

Venue Requested

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Referral Source Name

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Referral Source Email

Please enter email address for confirmation email of details

Helpful information about client availability or problems

Working

Working away or shifts

At home with small children

Appointment in school hours

Transport/Mobility problems

Physical or mental health issues

Other requirements eg Interpreter

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Any allegations of:

Domestic Violence/Abuse

Alcohol/Drug abuse

Mental health issues

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Please describe as appropriate:

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Issues for Mediation

ChildrenProperty & FinanceOther Issues (Please Specify) Invalid Input

If you have children please tell us their ages

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Details of solicitor advising in this matter:

Details of solicitor if known:

Solicitor for Client 1

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Name of Firm for Client 1's Solicitor

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Town

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Telephone Number for Client 1's Solicitor

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Solicitor for Client 2

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Name of Firm for Client 2's Solicitor

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Town

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Telephone Number for Client 2's Solicitor

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Client's choice of meeting

Single

Joint

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Reason for a separate meeting

If allegations of current domestic abuse a single appointment will be offered

Reason for Separate Meeting

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Any Other Relevant Information

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Solicitors Referral Form

Solicitor/CAB (other Agencies) referral for first appointment with a Mediator

Client 1 Applicant Details:

Client 2 Details:

Details of solicitor advising in this matter:

Details of solicitor if known:

Reason for a separate meeting