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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
No
The young person lives in East Sussex.
(Required)
Yes
No
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
No
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?
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
No
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)
DD slash MM slash YYYY
Address
(Required)
Street Address
Address Line 2
Town/City
County
Postcode
Mobile
Email
Name of school or college (if applicable)
Preferred contact method (if over 16 years old)
Text
Phone call
Email
By post
Are there any other young people involved?
(Required)
Yes
No
Second young person
Name
(Required)
First
Last
Has this person agreed to speak to our service?
(Required)
Yes
No
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)
DD slash MM slash YYYY
Does this young person live at the same address?
(Required)
Yes
No
Address
Street Address
Address Line 2
Town/City
County
Postcode
Mobile
Email
School
Preferred contact method (if over 16 years old)
Text
Phone call
Email
By post
Are there other young people involved?
(Required)
Yes
No
Third young person
Name
(Required)
First
Last
Has this person agreed to speak to our service?
(Required)
Yes
No
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)
DD slash MM slash YYYY
Does this young person live at the same address?
(Required)
Yes
No
Address
Street Address
Address Line 2
Town/City
County
Postcode
Mobile
Email
School
Preferred contact method (if over 16 years old)
Text
Phone call
Email
By post
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
No
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
Email
By post
Is there another adult involved?
(Required)
Yes
No
Adult 2
Name
First
Last
Has this person agreed to speak to our service?
(Required)
Yes
No
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
No
Address
Street Address
Address Line 2
Town/City
County
Postcode
Mobile
Email
(Required)
Preferred contact method
Text
Phone call
Email
By post
Is there another adult involved?
(Required)
Yes
No
Adult 3
Name
First
Last
Has this person agreed to speak to our service?
(Required)
Yes
No
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
No
Address
Street Address
Address Line 2
Town/City
County
Postcode
Mobile
Email
(Required)
Preferred contact method
Text
Phone call
Email
By post
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. Please select dates and times which might be possible for initial mediation meetings. These are normally held out of school hours, some time between 3:30pm and 7pm. Offering more dates makes it more likely we will be able to match you with mediators.
What would be the family's preferred meeting venue
(Required)
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
DD slash MM slash YYYY
1st time
Morning
Afternoon
After school/evening
Anytime
2nd date
DD slash MM slash YYYY
2nd time
Morning
Afternoon
After school/evening
Anytime
3rd date
DD slash MM slash YYYY
3rd time
Morning
Afternoon
After school/evening
Anytime
4th date
DD slash MM slash YYYY
4th time
Morning
Afternoon
After school/evening
Anytime
Any more dates?
Yes
No
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?
So sorry! I'm afraid 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.
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