01323 738258

enquiries@accordmediationservices.com

REFERRAL FORM

Information given to us on the form and at any assessment meeting is confidential and will not be shared with any (ex-)partner unless you give us permission to do so. In particular, your contact details will not be disclosed. However, if we proceed into mediation, we will ask if this completed sheet can be shared with your (ex-) partner. Do telephone us if you have any queries.

If you are a referring Solicitor or other Agency please complete all contact details here:

CONFIDENTIALITY & PROTECTION - SCREENING

Mediation is confidential but there are occasions when we are obliged to breach confidentiality either in relation to Child Protection or other abuse, or breaches of the Proceeds of Crime Act 2002 (see our information elsewhere).

PLEASE COMPLETE (A) , (B) or (C) below:

YOUR REASONS FOR COMING TO MEDIATION:

Please tell us what you think your main objectives are likely to be in mediation. We appreciate that you need to know more about the process of mediation from us but it would be helpful to us to have some idea of what you hope to achieve with our help.


IF THERE ARE ANY RELEVANT CHILDREN, PLEASE COMPLETE THE FOLLOWING – EVEN IF THEY ARE NOT THE SUBJECT OF ANY DISPUTE.

PRELIMINARY OUTLINE OF FINANCIAL POSITION

If financial matters are to be considered, a detailed questionnaire will be provided after your first session. Meanwhile, some preliminary information would be helpful, but will be treated in confidence:

THE FAMILY HOME:

If owned, please state:
£
£

DETAILS OF OTHER SUBSTANTIAL ASSETS & LIABILITIES

EMPLOYMENT:

£
If self-employed:
£

PUBLIC FUNDING BY THE LEGAL SERVICES COMMISSION – ADDITIONAL INFORMATION:

We may need to assess your eligibility for Public Funding at our first session, and the following information will help us to do this effectively. This information will not be shared with your (ex-) partner if mediation does not commence; the information is for us to provide a confidential assessment of your eligibility.

DOCUMENTARY PROOF TO BE BROUGHT WITH YOU:

Please provide for yourself and any current partner:

YOU

PARTNER

£
£
£
£
£
£
£
£

Certain expenses can now be taken into account in assessing eligibility. Please let us know any of the following paid by you:

£
£
£

In any event please bring some evidence of any earnings by providing a recent payslip or your most recent accounts.

FURTHER INFORMATION OR NOTES