Some clients will be self referred for Family Mediation, others may be referred by their solicitor, the courts, their counsellor, their faith leader, their friends, or by another organisation.

It is quite in order to self refer back to the Family Mediator  in the future should your situation call for further facilitation/ informal dispute resolution, perhaps if new circumstances should arise.

Please complete the form below and return it to the Family Mediator.   If you are being referred by a solicitor please can the solicitor complete this and return it to us prior to your client's mediation information and assessment meeting. It is essential that  the client speaks directly with us to arrange the appointment.Client Referral From

Referrer's Name *

Firm/Organisation Name *

Address *

Post Code *

Referrer Ref

Telephone Number *

Title Mr Mrs Miss Ms

Clients Name *

Address *

Post Code *

Primary Telephone *

Secondary Telephone

Email

Date of Birth ...

Tiltle Mr Mrs Miss Ms

Other Party's Name *

Address

Post Code

Primary Telephone *

Secondary Telephone

Email

Date of Birth ...

Name

Date of Birth ...

Gender Male Female

Name

Date of Birth ...

Gender Male Female

Name

Date of Birth ...

Gender Male Female

Name

Date of Birth ...

Gender Male Female

Please select All Issues Property and Finance only Children only Other

Status Don't Know Legally Aided Privately Funded

Please select ...

Human Verification

Thank for your referral, we will be in contact soon.