Family Mediation Referral Form

Private Funded Mediation Assessment

Printable version of the form
Complete and post to Shire MediationYou can complete the form yourself or alternatively your solicitor can use the form to refer you to mediation.

* Required Field

Shire Mediation details

Shire Mediation, Unit 121, 5 High Street, Maidenhead, SL6 1JA
Tel: 01628 626312 / 01628 623555
Email: jane@shire-mediation.co.uk

* I have read and understand the privacy policy

Referrer's details

Referrer's Name *:

Firm or Organisation Name:

Referrer's Address:

Post Code:

Email *:

Telephone:

Client's details

Client's Name *:

Mr/Mrs/Miss/Ms *:

Client's Address *:

*Post Code :

Email:

Telephone *:

Date of birth (dd/mm/year):

Other party's details

Other Party's Name *:

Mr/Mrs/Miss/Ms *:

Other Party's Address *:

Post Code *:

Email:

Telephone *:

Date of birth (dd/mm/year):

Other party's solicitor details (if any)

Name of Solicitor:

Name of Firm:

Address:

Post Code:

Email:

Telephone:

Children

Name (Required)*	Date of birth	Male	Female

If no children please enter 'None'.

Mediation sought

Type of mediation sought *:

Date of referral (dd/mm/year) *:

Random
* Please copy the code above (case sensitive)