Online Referral for Family Mediation

Applicant
First Name :		Surname :
Address :		Town :
County :		Postcode :
Home Telephone :		Mobile Telephone :
Work Telephone :
Email address :		Confirm email :
Is there any history of domestic violence?			Yes No
Does the applicant have a disability?			Yes No
Does the applicant require an interpreter?			Yes No
Solicitor acting for former partner:
Contact :		Telephone :
Former Partner
First Name :		Surname :
Address :		Town :
County :		Postcode :
Home Telephone :		Mobile Telephone :
Work Telephone :
Is the former partner aware of this referral and are they willing to proceed with mediation?			Yes No
Is there any history of domestic violence?			Yes No
Does the applicant have a disability?			Yes No
Does the applicant require an interpreter?			Yes No
Children
Name	Date of Birth	Living With
Have court proceedings commenced?
Court Reference :		Date of Hearing :
Are CAFCASS Involved?			Yes No
Issues to be addressed in Mediation:
Children	Property & Finance Other
Any other relevant information?
Solicitor making this referral:
Contact :		Telephone :
Firm :		Date :
Is this referral under the Funding Code CLS App7?			Yes No