Confidential Questionnaire

Please complete this form and press submit. All fields marked with a * must be completed. If a pre-Court FM1 Willingness Test is requested the £50+VAT fee will need to accompany this form. If this is the case please download the mediation form and send it with your cheque for £60, made payable to Anthony Gold Solicitors, to:

Anthony Gold Mediation, DX 58604 Streatham
or Lloyds Bank Chambers, 186 Streatham High Road, London, SW16 1BG

Name of person completing form*

Are you: the client a referring solicitor

Date

Your Details (or Your Clients if Solicitors Referral)

Title Mr Mrs Miss Ms Dr

Name

Address

Tel No

Mobile

Email*

You will be emailed a copy of the submitted form for your records.

Solicitor's Details (if any)

Firm's Name

The Solicitor Acting and Ref No

DX (or address if none)

Tel No

Fax No

Email

Partner/Former Partner's Details

Title Mr Mrs Miss Ms Dr

Name

Address

Tel No

Mobile

Email

Partner/ Former Partner's Solicitor's Details (if any)

Solicitor's Firm Name (if any)

The Solicitor Acting and Ref No

DX (or address if none)

Solicitor's Tel No

Solicitor's Fax No

Solicitor's Email

Is this a referral linked to applying for Legal Aid (CLSAPP7)? Yes No

Is this a referral linked to applying to the Court (FM1)? Yes No

Does either party (to your knowledge) have an existing Legal Aid Certificate? Yes No

Normally before a meeting is fixed, we undertake the willingness test on the other party.

Please indicate here if you/your client first want to establish if the other party will come to a meeting (the Willingness Test.) Our guidance explains that there may be a fee chargeable in advance if neither party is eligible for Legal Aid.

Please indicate here if you/your client would prefer to attend an information and assessment meeting before the willingness test so as to obtain further information about mediation.

Please indicate here whether, if the other party indicates a willingness, you/your client would prefer an individual information and assessment meeting. (Please note that even joint meetings start with individual sessions for 10-15 minutes)

Have any court proceedings commenced? Yes No

If so, what proceedings, in which Court and what stage has been reached?

Type of Mediation Sought?

Relationship Breakdown	Property and Finance only
Children only	All issues

Names and ages of any relevant children

Has there been any history (alleged or actual) of violence, harassment, intimidation or child protection concerns? Yes No

Which is the more convenient location? London Bridge Streatham

Mandatory: To help us distinguish between forms submitted by individuals and those automatically generated by spam software, please type the word shown here into the box below.