Mediation Referral Form : Wilson Browne

Mediation Referral Form

*Please be assured that the information you provide will remain confidential until an agreement to mediate has been signed

Who is this mediation (MIAM) for?

YOU

YOUR SOLICITOR'S DETAILS

THE OTHER PERSON INVOLVED OR PERSON YOU WANT TO MEDIATE WITH

(even if this is a sole MIAM, we need to know the name of the other person in the relationship)

THEIR SOLICITOR'S DETAILS

DETAILS

The issues you want to discuss in mediation: Children
Property/Finances
Divorce/Separation
Communication

Names & Dates of birth of any Children:

DOB*

Brief details of any Court proceedings and the stage those have reached:

Where did you find out about mediation?

Please confirm we can proceed to invite you and the other person to a mediation information and assessment meeting

Would you like the New Enquiries Team to give you a call