Sue West Family Mediation

Sue West Family Mediation Referral for Mediation Assessment

CLIENT A CLIENT B

Name: Name:

Address Address

Main telephone no: Main telephone no:

Alternative telephone no: Alternative telephone no:

E-mail address: E-mail address:

Legal advisor (name, firm and address) Legal advisor (name, firm and address)

Tel. no Tel no. Children (optional) Name Date of birth

Is the referral for a MIAM? Yes/No If yes indicate preference for meeting to be? Joint/Separate

Issues for mediation: Children / Finance and property / Both

Any indication of domestic abuse/child protection issues? Yes/No If yes provide brief details and consider whether the assessment meeting should be held separately.

Is your client likely to be eligible for Legal Aid funding? Yes/No

Has the other party agreed to mediation? Yes/No If yes, if both clients privately funded and no abuse issues is Quickstart Mediation required? Yes/No

Referred by: ______Date: ___/___/____

15/4/2014