Mediation Form

Complete our mediation form online

You can print out our mediation form here, or contact us online by completing the form below.

Your Details

Your Name (required)
Your Address
Home Tel:
Work Tel:
Mobile:
Your Email (required)
Is the above information confidential from the other person?
Yes No 

Details of Your Solicitor

Your Solicitor

Firm

Firm address

Firm tel

Firm email


Check this box if you think you may be eligible for public funding (free mediation)? You can check eligibility online at www.gov.uk/check-legal-aid.
I believe I am eligible for legal aid 

Details of ex partner/other party

Name

Address

Home tel

Work tel

Mobile tel


Details of ex partner/other parties solicitor

Solicitor

Firm

Address

Tel

Email


Are you married?
Yes No 

If so, date of marriage:

Date of cohabitation:

Date of separation:

Children - names and dates of birth:


Issues for mediation