Self Referral Form

Please submit the form below if you are being referred by a solicitor. For referring solicitors please complete this and return it to us prior to your client’s Mediation Information and Assessment Meeting. It is essential that your client speaks directly with us to arrange the appointment.

If you are wishing to “self refer” to mediation, please check the corresponding field.

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Are you being referred by a solicitor or is this a self referral?
Name
Is your address confidential from other party?
Former Partner Name
Type of Mediation Sought
Has there been any history (alleged or actual) of violence, harassment, intimidation or child protection concerns?