Mediation Plus

Providing Mediation, Conflict Resolution and Training for our Community

Neighbourhood Mediation

Self Referral Form

Please complete all fields to enable us to process the referral.

When you are asked to ‘Choose an item’, please select and choose a drop-down option.

If you need assistance completing the form or have any questions about the information required, please feel free to contact us.

Neighbourhood Mediation – Self Referral Form

District(Required)

Are there any agencies involved? (e.g police, housing or another service?(Required)

Yes

Please give details

First Party Details (You)

Name(Required)

Address(Required)

Street Address Address Line 2 City County Post Code

Landline

Mobile

Preferred Contact Method

Can Mediation Plus leave a message the home/mobile phone?(Required)

Yes

Do you have any health, access or support needs that would like to make us aware of?

Is there a risk of homelessness?(Required)

Yes

Second Party Details

Leave this section blank, if you are making a referral for one to one support / conflict coaching.

Name

Address

Street Address Address Line 2 City County Post Code

Landline

Mobile

Preferred Contact Method (if known)

Do they have any health, access or support needs that you are aware of?

Do they know you are making this referral?

Yes

The Dispute

Reason for the Referral

Noise

Pets

Boundary Issues

Communication Issues

Children

Lifestyle Clash

ASB / Harrassment

Other

Brief Outline of Dispute:

Have you spoken to your neighbour about the issue? And how did it go?

How long has this being going on?

Did you ever have a positive relationship with your neighbour?

Thinking about your situation, (where 1 is negative and 10 is positive), please indicate how you are feeling now?

Have you done anything else to try to resolve the dispute?

(Please include any legal proceedings)

Any other relevant information

Untitled

First Choice

Second Choice

Third Choice

Phone

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