Referral to mediation- legal and professional Referrer DetailsName of Referring Professional*Firm/Agency Name*Contact Number*Contact Email*⯅ Important: Please ensure this is correct as we will send a confirmation email to this address.Where did you hear about us?SourceWeb SearchWord of mouthSocial mediaSolicitorCitizens Advice BureauIssueReason*Arrangements for childrenArrangements for financesArrangements about children and financesDo you want to talk about financial support for children?NoYesDo you want to talk about arrangements for a house, pension or liabilities?NoYesPlease tell us moreABOUT YOUR CLIENTTitle*Please chooseMrDrDr(f)Dr(x)IndMissMrsMr and MrsMr and MrMrs and MrsGenderPlease chooseMaleFemaleNonbinaryPrefer not to sayNone of the aboveThey would describe themself as:First Name*Surname*Address Line 1*Address Line 2City / Town*County*Post Code*Contact Number*Email* Date of Birth*What is their National Insurance number?Occupation*How would you describe their ethnicity?*Prefer not to sayWhiteBlackAsianChineseMixed HeritageTravellerPlease choose:White BritishWhite IrishWhite OtherPlease choose:Black BritishBlack CaribbeanBlack AfricanPlease choose:Asian IndianAsian PakistanAsian BangladeshiPlease choose:Mixed White / Black AfricanMixed White / Black CaribbeanMixed White / AsianDo they have a disability?NoYesHow would you describe their disability?Disability visibleDisability not visibleLearning disabilityLong Standing illness or health conditionMental health conditionOtherUnknownBlindVisually impairedDeaf / Hearing impairedWould you like to provide more information about their disability?Preferred contact method for your client* Phone Email Text What time should we call your client?Before 9amBetween 9am & 3pmBetween 3pm & 7pmWill your client need support coming to or taking part in their meeting?NoYesPlease give details of the support required:ConfidentialityIs their email address confidential?YesNoIs their postal address confidential?YesNoIs their telephone number confidential?YesNoAbout the other partyName*Surname*Address Line 1*Address Line 2City / Town*CountyPost CodeContact Number*Email Date of birth:What is their occupation?About the childrenNameGenderDate of birthAdd Another Child Add Another Child NameGenderDate of birthAdd Child 2 Add Another Child NameGenderDate of birthAdd Child 3 Add Another Child NameGenderDate of birthSafetyHave the police been contacted?NoYesCan you please give more detail?Was any action taken?NoYesAre any orders in place?NoYesIs there a harassment order in place?NoYesIs there a molestation Order in place?NoYesAre there any conditions relating to contact between the parties ?NoYesWhat type of conditions? Bail Conditions Injunction You can use this space to upload a court order or a letter setting out bail conditions Drop files here or Are children’s services currently involved?NoYesCan you tell us more? (e.g. what type of involvement /CIN plans are in place/Court orders)Any other information you would like to provide?Would you like us to update you?YesNoHow would you like us to contact you? Phone Email UntitledFirst ChoiceSecond ChoiceThird ChoiceNameThis field is for validation purposes and should be left unchanged.
