Begin the process

Family Mediation Referral Form

Complete the form below to begin the family mediation process. We'll be in touch to arrange your initial Mediation Information and Assessment Meeting (MIAM) - an individual meeting where we explain the process and assess whether mediation is suitable for your situation.

You can also download our Agreement to Mediate.

Fields marked * are required. Some questions only appear when relevant to your answers.

Part 1. General Information

Your details

Surname *

Forenames *

Date Of Birth *

Address *

Street Address

Address Line 2

City

ZIP / Postal Code

Who owns this property?

Please give details of who owns the property

What is the approximate market value of the property?

What is the rent per month?

Is it subject to a mortgage?

How much is the monthly repayment?

How much is outstanding on the mortgage?

Is the property owned in joint tenancy or tenancy in common?

Did you and your ex-partner live together in this property as a couple?

Preferred phone number *

Email *

Your former partner’s details

Surname *

Forenames *

Date Of Birth *

Address

Street Address

Address Line 2

City

ZIP / Postal Code

Preferred phone number

Confidentiality

Do you need us to keep your contact details secret from your ex-partner?

If so, which?

Part 2. Legal proceedings and issues for discussion

Have you consulted a solicitor or other qualified legal practitioner for advice on the issues you want to discuss in mediation? *

Have you instructed a solicitor or another legal practitioner to act for you? *

Name

Firm

Are you currently engaged in or contemplating divorce proceedings? *

Is the divorce application an individual or joint application?

Is the divorce process something you want to discuss during the mediation?

Are you currently on police bail with bail terms imposed by the police or by the court? *

What are the terms of the bail conditions? *

Are you currently subject to an Order of the Court regarding contact with your ex-partner or any other party? *

What are the terms of the Court Order? *

Issues for discussion during mediation

Would you like to discuss property and finance, including pensions?

Would you like to discuss the arrangements for children?

Would you like to discuss the payment of child maintenance?

Would you like to discuss the payment of spousal maintenance?

Would you like to discuss communications issues between you and your ex-partner?

Are there any other issues you would like to discuss?

What are they?

Part 3. Relationship details

Please provide all the dates which apply to you:

Cohabitation: mm/yyyy

Marriage or civil partnership: mm/yyyy

Separation: mm/yyyy

Petition to the court: mm/yyyy

Decree nisi or Conditional Order: mm/yyyy

Decree absolute or Final Order: mm/yyyy

Do you live with someone as part of a relationship?

When did you begin living with your new partner? mm/yyyy

Do you intend to begin living with someone as part of a relationship in the next 12 months?

Do you intend to marry or enter into a civil partnership in the next 12 months?

What is the expected date of the event? mm/yyyy

Other Information

Have you or your ex-partner had any form of relevant counselling or therapy or been involved with any professionals offering support to the relationship?

Please give brief details of the type of support

Are there any issues of protection, violence or safety involving you, your former partner or children which we may need to address? *

Please give details *

At our first meeting, your ex-partner will not be present. After that, mediation normally takes place with both of you in the room at the same time. Are there any reasons why you would wish to start the first joint session separately? *

Please briefly explain why *

Discussions about mediation

Have you discussed mediation with your ex-partner?

What was their reaction?

Have you attempted mediation with your ex-partner before?

What was the outcome?

Would you like us to contact your ex-partner to invite them to take part? This will not happen until after your individual meeting with your mediator.

Part 4. Children

Do you have any children under the age of 18?

Please give the details of any children whom you regard or have treated as your own and with whom they live, even if they are not also the children of the other participant in this mediation:

How Many Children?

Child 1

Forename

Surname

Date of birth

General state of health:

Currently lives mostly with:

Do you have legal parental responsibility for this child? This is afforded to the mother automatically and to the father if: (a) he is named on the birth certificate; or (b) he was married to the mother at the time of the child’s birth

Child 2

Forename:

Surname:

Date of birth

General state of health:

Currently lives mostly with:

Do you have leal parental responsibility for this child? This is afforded to the mother automatically and to the father if: (a) he is named on the birth certificate; or (b) he was married to the mother at the time of the child’s birth

Child 3

Forename:

Surname:

Date of birth

General state of health:

Currently lives mostly with:

Child 4

Forename:

Surname:

Date of birth

General state of health:

Currently lives mostly with:

Child 5

Forename:

Surname:

Date of birth

General state of health:

Currently lives mostly with:

Child 6

Forename:

Surname:

Date of birth

General state of health:

Currently lives mostly with:

Section Break

Are the arrangements for children to be discussed during the mediation?

What are the current arrangements for looking after this child or these children?

Are these arrangements the subject of an existing court order?

Do you want to discuss amending those arrangements?

What alternative proposal would you like to make?

If these are also the children of the other party to the mediation, is child maintenance being paid in respect of them?

How much?

How often?

Please briefly explain why.

Has the Child Maintenance Service been involved in assessing or collecting Child Maintenance in respect of these children?

Part 5. Financial information

In addition to the property listed in Part 1, do you have a legal or beneficial interest in any other property?

Please give brief details:

What is the equity in that property?

What is your share of that equity?

Are you in paid employment?

What is your occupation?

What is your current total gross (i.e. before any tax or national insurance are deducted) monthly income?

Are you in receipt of any state benefits?

Please list them.

Do you have any other source of income either in the UK or elsewhere?

What is the source of that income?

How often do you receive it?

Part 6. Other information

Please indicate what issues you feel need to be considered during the mediation, and what your aims are in coming to mediation. Please also provide any other information that you feel the mediator should know at this stage:

Part 7. Personal declaration

Confirmation I confirm that the information given in this form is a full, frank and accurate disclosure of my financial and other relevant circumstances. I have read and accept the terms and conditions of the mediation process detailed in the Hampshire Mediation Agreement to Mediate for family mediation, including the fees that Hampshire Mediation charges and its cancelation policy. By applying to take part in mediation, I agree to be bound by those terms. I understand that, unless I qualify for legal aid (which my mediator will determine before the mediation begins), that I will be responsible for my fees.

Name *

Date *

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