Sussex-wide, incorporating Brighton and Hove Independent Mediation Service. Read more.

Time2Talk Mediation Referral Form

Please fill in this form to refer to our Time2Talk mediation services.

2025 2026 Time2Talk referral form

REFERRAL GUIDANCE

The Time2Talk project supports young people and their parents and carers to resolve conflict through mediation. Our support is impartial, non-judgemental and confidential (unless we believe someone is at risk of harm).

Our service can provide support with:

– Families arguing over a specific issue, or several issues.

– Communication problems.

– Relationship breakdowns between young people and their parents/carers.

If adults in a family are arguing about child arrangements, family mediation may be more suitable.

CRITERIA

Before completing this form, please check that your case meets our criteria:

The young person involved is between 11 and 18 years old.(Required)

Yes

The young person lives in East Sussex.(Required)

Yes

All those involved are willing to speak to us and have a one-to-one meeting with our mediators, as a starting point.(Required)

Yes

Mediation is voluntary. Please do not complete this form unless you have everyone’s consent to take part.

WHO IS COMPLETING THE FORM

Name(Required)

First Last

Are you in family or from an external support agency?(Required)

Part of the family (self-referral)

From a support agency (eg CAMHS, Early Help)

Relationship to the young person(Required)

Eg mother, uncle, step-father

Job title(Required)

Agency(Required)

Mobile(Required)

Email(Required)

How did you hear about our service?(Required)

THE YOUNG PEOPLE INVOLVED

Please provide details of all the children and young people involved

Name(Required)

First Last

Has this person agreed to speak to our service?(Required)

Yes

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 Town/City County Postcode

Mobile (if over 16 years old)

Email (if over 16 years old)

Name of school or college (if applicable)

Preferred contact method (if over 16 years old)

Text

Phone call

Are there any other young people involved?(Required)

Yes

Second young person

Name(Required)

First Last

Has this person agreed to speak to our service?(Required)

Yes

n/a – not taking part

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Date of Birth(Required)

Does this young person live at the same address?(Required)

Yes

Address

Street Address Address Line 2 Town/City County Postcode

Mobile (if over 16 years old)

Email (if over 16 years old)

School

Preferred contact method (if over 16 years old)

Text

Phone call

Are there other young people involved?(Required)

Yes

Third young person

Name(Required)

First Last

Has this person agreed to speak to our service?(Required)

Yes

n/a – not taking part

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Date of Birth(Required)

Does this young person live at the same address?(Required)

Yes

Address

Street Address Address Line 2 Town/City County Postcode

Mobile (if over 16 years old)

Email (if over 16 years old)

School

Preferred contact method (if over 16 years old)

Text

Phone call

THE ADULTS INVOLVED

Please list the parents/carers/other adults who will be involved.

Name(Required)

First Last

Has this person agreed to speak to our service?(Required)

Yes

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Relationship to young person

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Address

Street Address Address Line 2 Town/City County Postcode

Mobile

Email(Required)

Preferred contact method

Text

Phone call

Is there another adult involved?(Required)

Yes

Adult 2

Name

First Last

Has this person agreed to speak to our service?(Required)

Yes

n/a – not taking part

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Relationship to young person

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Does this person live at the same address as Adult 1?(Required)

Yes

Address

Street Address Address Line 2 Town/City County Postcode

Mobile

Email(Required)

Preferred contact method

Text

Phone call

Is there another adult involved?(Required)

Yes

Adult 3

Name

First Last

Has this person agreed to speak to our service?(Required)

Yes

n/a – not taking part

So sorry! We can’t go ahead without the consent of all those involved. Please ask this person if we can contact them and resubmit the referral only if you have their agreement.

Relationship to young person

Gender

Male

Female

Non binary

Another gender

Prefer not to say

Does this person live at the same address as Adult 1?(Required)

Yes

Address

Street Address Address Line 2 Town/City County Postcode

Mobile

Email(Required)

Preferred contact method

Text

Phone call

WHAT HAS BEEN HAPPENING?

Who is the mediation between, what are the main issues affecting the family and what would you/they like to achieve through mediation?

Please list any other support services involved

Are there any risks or additional needs for any of the family members that we should be aware of?

Eg physical or mental health or additional needs.

OTHER INFORMATION

It is helpful to know when and where meetings can take place, so we can match up with suitable mediators.

Are you able to suggest some dates for a first meeting with the family?(Required)

Yes

What would be the family's preferred meeting venue

St Leonards on Sea office

Hailsham office

Online

Would not be able to travel to an office or meet online

Most meetings take place in our offices or online.

1st date

1st time

Morning (10am to 12 noon)

Afternoon (1pm to 3pm)

After school/evening (4pm to 6pm)

2nd date

2nd time

Morning (10am to 12 noon)

Afternoon (1pm to 3pm)

After school/evening (4pm to 6pm)

3rd date

3rd time

Morning (10am to 12 noon)

Afternoon (1pm to 3pm)

After school/evening (4pm to 6pm)

4th date

4th time

Morning (10am to 12 noon)

Afternoon (1pm to 3pm)

After school/evening (4pm to 6pm)

Any more dates?

Yes

The more dates you can suggest the more likely we are to be able to match you with mediators. Are you able to suggest another date?

Sorry! We are unable to help you at this time.

We can only help young people aged between 11 and 18 who are living in East Sussex, and where all those involved in the case are willing to participate.