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)