Your Name

Your Address

Your Telephone No.

Email Address

Address of person to mediate with (the second party)

Name of person to mediate with (the second party)

General Availability for Appointments?

Email address of person to mediate with (the second party)

Telephone No. of person to mediate with (the second party)

Name and ages of any relevant children

Please tell us a little bit about why you would like to consider mediation at this time.

Name of person completing this form if not party one

Organisation completing this form if not party one

Email of person completing this form if not party one

Date referral made if person completing this form if not party one

Would you like to receive information about the progress of this matter?

Any additional notes