Client Contact Form

Please fill in as much as you can, we will then contact you to discuss it or arrange your Mediation Information Assessment Meeting (MIAM) with one of our mediators.

Your Details:

Name

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Address

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Postcode

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Mobile Telephone Number

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Email address(*)

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Occupation

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Your DOB

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Your National Insurance Number

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Other Party Details:

Name

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Address

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Postcode

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Mobile Telephone Number

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OP Email address

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Occupation

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OP DOB

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1st Child's Details

Child's name

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Child's Gender

Male

Female

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Child's Date of Birth

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Living With

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2nd Child's Details

Child's name

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Child's Gender

Male

Female

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Child's Date of Birth

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Living With

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3rd Child's Details

Child's name

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Child's Gender

Male

Female

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Child's Date of Birth

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Living With

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4th Child's Details

Child's name

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Child's Gender

Male

Female

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Child's Date of Birth

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Living With

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Issues for Mediation

Children

Property & Finance

Other Issues (Please Specify)

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Other Issues for Mediation

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Do you want information and to be assessed for Legal Aid for mediation?

YesNo Invalid Input

Details (if known) of solicitors advising in this matter:

Your Solicitor

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Name of your Solicitor's Firm

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Other Party's Solicitor

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Name of other Party's Solicitor's Firm

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Do you or the other party have any additional needs? (e.g. interpreter or support worker)

YesNo Invalid Input