Home > Mediation > Solicitors Referral Form

Your Details

Your Name
Email Address
Telephone
FAX
Firm Name
Firm DX

Preferred Venue

Bungay
Bury St Edmunds
Gorleston
Ipswich
Lowestoft
Norwich
Wymondham
Kings Lynn

Client details

Name Maiden Name
Address D.O.B
  National Insurance No.
  Tel Home
Postcode Tel Work
Email Tel Mobile
    Ethnic Origin

Can these details be disclosed? Yes No
Legal help Yes No
Private Yes No
If private, does your client hope to apply for public funding if mediation proves unsuitable? Yes No

Other client details

Name Maiden Name
Address D.O.B
  National Insurance No.
  Tel Home
Postcode Tel Work
Email Tel Mobile
Ethnic Origin    
Solicitor Firm
DX Telephone
Email Fax
Has the Solicitor agreed a referral? Yes No
Is the other party aware of referral? Yes No
Is the other party willing to accept an appointment? Yes No
Has divorce been filed? Yes No
Has the Court Welfare Service or any other Social Agency
been involved, either now or in the past?		 Yes No
Date of marriage
Date of separation
Decree Nisi date
Decree Absolute date
Any relevant Magistrates Court Orders?
Any relevant pending Court hearings?
If so, for what and date?

Children's names and dates of birth
With whom currently living?
Apparent issues for mediation
Availability for interview
Any disabilities we should be aware of?