Their Solicitor's Details Their Solicitor's Firm Name
The Solicitor Acting and Ref No
DX (or address if none)
Solicitor's Phone Number
Solicitor's Fax Number
Is this a referral under the Funding Code of the Access to Justice Act? ---Please Choose--- Yes No
Normally before a meeting is fixed, we shall undertake the willingness test on the other party.
Please indicate if your client agrees to first carry out the willingness test on the other party ---Please Choose--- Yes No
Please indicate if your client would prefer to attend an assessment meeting before the willingness test so as to obtain further information about mediation ---Please Choose--- Yes No
Please indicate whether, if the other party indicates a willingness, your client would prefer an individual assessment meeting (please note that even joint meetings start with individual sessions for 10-15 minutes) ---Please Choose--- Yes No
Have any Court proceedings commenced? ---Please Choose--- Yes No
If Yes, what proceedings, in which Court and what stage has been reached?
What type of mediation is sought? ---Please Choose--- Relationship breakdown Children only Property and finance 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? ---Please Choose--- Yes No
Name of Referrer
Date
