Solicitors Referral Form

Solicitor/CAB (other Agencies) referral for first appointment with a Mediator

Venue Requested

Please Choose:Bognor RegisBrightonChichesterClapham CommonCrawleyCroydonEast GrinsteadEastbourneHastings/St Leonards on SeaHaywards HeathHorshamLewesLondonRedhillSuttonWorthing

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Referral Source Name

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Referral Source Email

Please enter email address for confirmation email of details

Client 1 Applicant Details:

Relationship

Relationship

Ex

Husband

Wife

Partner

Other

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Title

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Name

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Address

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Postcode

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Home Telephone

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Mobile Telephone Number

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Email address

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Client 2 Details:

Relationship

Relationship

Ex

Husband

Wife

Partner

Other

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Title

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Name

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Address

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Postcode

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Home Telephone 2

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Mobile Telephone Number

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Email address

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Helpful information about client availability or problems

Helpful information about client availability or problems

Working

Working away or shifts

At home with small children

Appointment in school hours

Transport/Mobility problems

Physical or mental health issues

Other requirements eg Interpreter

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Any allegations of:

Any allegations of:

Domestic Violence/Abuse

Alcohol/Drug abuse

Mental health issues

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Please describe as appropriate:

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Issues for Mediation

Issues for Mediation

Children

Property & Finance

Other Issues (Please Specify)

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If you have children please tell us their ages

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Details of solicitor advising in this matter:

Details of solicitor if known:

Solicitor for Client 1

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Name of Firm for Client 1's Solicitor

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Town

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Telephone Number for Client 1's Solicitor

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Solicitor for Client 2

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Name of Firm for Client 2's Solicitor

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Town

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Telephone Number for Client 2's Solicitor

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Client's choice of meeting

Client's choice of meeting

Single

Joint

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Reason for a separate meeting

If allegations of current domestic abuse a single appointment will be offered

Reason for Separate Meeting

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Any Other Relevant Information

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