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?
    YesNo

    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?
    YesNo

    If so, date of marriage:

    Date of cohabitation:

    Date of separation:

    Children - names and dates of birth:

    Issues for mediation