Mediation Referral Form

If you would like us to contact you please complete our form below. Fill in what you can but fields marked (required) must be completed. Or if you would prefer call us on the number shown in our contact page.

    Your Information

    Former Partners Information (If not known write n/a)

    You can refer yourself with or without your former partner’s agreement, but please confirm whether they are aware of this referral.

    Would you prefer a joint or separate assessment meeting?

    What are the likely issues?

    Does the former partner know about the impending divorce/separation?

    Would you prefer us to write or telephone your former partner?

    Has there been any history (alleged or actual) of domestic abuse including violence, harassment, intimidation or child protection concerns?

    Anything else you would like to tell us that you think might be helpful

    Thank you for filling in this form. Someone will get back to you within one working day.