Family Mediation Referral Form

Please fill in this form to refer to our family mediation services for mediation between separating / separated adults.

Family Mediation – Referral Form

Legal Aid Support

You may be entitled to legal aid funded mediation if you or your ex-partner are on benefits, have a household income of less than £2,657 per month (if you live with a partner, their income will be calculated in this), and have savings of under £8,000.

Do you think you or your ex-partner are entitled to legal aid funding?(Required)

Yes

Don’t know

Unfortunately we are unable to support you with legal aid funded mediation. Please do not submit this form.

You can visit https://find-legal-advice.justice.gov.uk/ to find a service that offers this support.

Name(Required)

First Last

Date(Required)

How did you hear about us?(Required)

Internet Search

National Family Mediation

Other

Have you used our Family Mediation service before?(Required)

Yes

Date you used our Family Mediation service before (leave blank if answered 'no' to above question).

Is any of your information confidential from the other party?(Required)

Yes

Contact Details

Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County Post Code

Telephone(Required)

Alternative Telephone

Other Party Details

Name(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City County Post Code

Telephone(Required)

Alternative Telephone

Children's Details

First name and surname

First Name and Surname

Date of Birth

Currently Living With

Useful Information

Areas for Mediation(Required)

Children

Finance

Property

Other

Are there any other reasons for needing mediation?

Thank you

Comments

This field is for validation purposes and should be left unchanged.