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Solicitors Referral Form
Solicitor/CAB (other Agencies) referral for first appointment with a Mediator
Venue Requested
Please Choose:
Bognor Regis
Brighton
Chichester
Clapham Common
Crawley
Croydon
East Grinstead
Eastbourne
Hastings/St Leonards on Sea
Haywards Heath
Horsham
Lewes
London
Redhill
Sutton
Worthing
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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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