Mediation for the Family Client Referral Form

If you are the female of the ex-partnership then you are only required to fill in the Wife/Partner section, or if you are the male then you are only required to fill in the Husband/Partner section. If you are able to fill in both sides of the form for both parties this will help us to process your referral more quickly. All applicants are to fill in part 2 of the form.

Part 1

Wife/Partner

Surname Former Name
Forename(s) Known As
Address
Postcode
Home Telephone
Office Telephone
Mobile Telephone
* if you supply telephone numbers for both parties this will help us to process your referral more quickly
Email Address
Date of Birth
Employed? YesNo
Occupation
Income Details
National Insurance Number
Welfare Benefits Received
Tax Credits
Solicitor
Ref Address
Telephone Number
Email Address
*Please complete if you would prefer us to contact you by email

Husband/Partner

Surname Former Name
Forename(s) Known As
Address
Postcode
Home Telephone
Office Telephone
Mobile Telephone
* if you supply telephone numbers for both parties this will help us to process your referral more quickly
Email Address
Date of Birth
Employed? YesNo
Occupation
Income Details
National Insurance Number
Welfare Benefits Received
Tax Credits
Solicitor
Ref Address
Telephone Number
Email Address
*Please complete if you would prefer us to contact you by email

Part 2

Important - This section MUST be completed

Please indicate if you have carried out money laundering checks regarding your client
Has your client or other party instructed previously any other solicitor which would create a conflict of interest for either party?
Has there been a history of abuse/violence in the relationship or between parties? If so please give details below
Do the parties require a separate appointment?
Do the parties require a separate waiting room?
Issue (i.e. finances)