Solicitors referral form

Your Name

Your Firm Name

Your Reference

Your Address

Postcode

DX

Telephone

Fax

Email

Client Name

Address

Postcode

Telephone

Fax

Email

 

We are happy to contact your client direct. If the mediation proceeds, we will confirm the appointment details with you. It would be helpful if you could provide us with the other party’s details below. Unless you specifically tell us otherwise, we will also contact them.

Name

Address

Postcode

Telephone

Fax

Email

Name

Your Firm Name

Your Reference

Your Address

Postcode

DX

Telephone

Fax

Email

Preferred location for mediation

 Emsworth Fareham Havant

 

Issues for mediation:

 Children Property & Finance Divorce/Separation All issues Consultation with children

 

Is your client already in receipt of legal help:

 Yes No

 

Is this a referral for a Mediation Information and Assessment Meeting?

 Yes No

 

Are there proceedings or injunctions?

 

It is crucial that we are told about safety or other issues, such as domestic violence before clients attend the
initial meeting. Do either of the clients have any concerns about:

 

Mental Health

 Yes No

 

Domestic Violence

 Yes No

 

Child Protection

 Yes No

 

Any special facilities required? If so please specify:

 

How did you hear about Mediation Now?

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Name: 
Date:   
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