<p> Sue West Family Mediation Referral for Mediation Assessment</p><p>CLIENT A CLIENT B</p><p>Name: Name:</p><p>Address Address</p><p>Main telephone no: Main telephone no: </p><p>Alternative telephone no: Alternative telephone no:</p><p>E-mail address: E-mail address:</p><p>Legal advisor (name, firm and address) Legal advisor (name, firm and address)</p><p>Tel. no Tel no. Children (optional) Name Date of birth</p><p>Is the referral for a MIAM? Yes/No If yes indicate preference for meeting to be? Joint/Separate</p><p>Issues for mediation: Children / Finance and property / Both</p><p>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.</p><p>Is your client likely to be eligible for Legal Aid funding? Yes/No</p><p>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</p><p>Referred by: ______Date: ___/___/____</p><p>15/4/2014</p>