Online Referral for Family Mediation

Referrer
First Name :
Surname :

Address :

Town :
County :
Postcode :
Home Telephone :
Mobile Telephone :
Work Telephone :
Email address :
Confirm email :
   
Is there any history of domestic abuse by the referrer?
Yes No
Does the referrer have a disability?
Yes No
Does the referrer require an interpreter?
Yes No
 

Solicitor if you have one:

Contact :
Telephone :
Name :
Email :
 
 
Former Partner
First Name :
Surname :

Address :

Town :
County :
Postcode :
Home Telephone :
Mobile Telephone :
Work Telephone :
Email :
   
Is the former partner aware of this referral?
Yes No
Is the former partner willing to proceed with mediation?
Yes No
Is there any history of domestic abuse by the former partner?
Yes No
Does the former partner have a disability?
Yes No
Does the former partner require an interpreter?
Yes No

Former Partner's Solicitor if known:

Contact :
Telephone :
Name :
Email :
 
 
Children
Name
Date of Birth
Living With
 
Have court proceedings commenced?
Court Reference :
Date of Hearing :

Are CAFCASS Involved?

Yes No
   
Please tick if you do not wish us to contact your former partner until after you have attended a MIAM
 
 
Issues to be addressed in Mediation:
Children
Property & Finance Other
 
Any other relevant information?
 
Please tick which office you prefer
Bloxham (Banbury)
Cirencester
Moreton in Marsh
Oxford
Winchcombe
Highworth (Swindon)