Book your appointment At the end of this form, you will either be asked to pay a £20.00 deposit if you are applying for legal aid or to pay the full amount for your appointment. If you are not in a position to pay today, please contact our office on 01302 369688. Your Case If we have sent you an email or letter, please add your case number (this will be in the subject line of your email or at the top of your letter).Case NumberWhat would you like to talk about?Reason*Arrangements for my childrenArrangements for my financesArrangements about children and financesPlease tell us more about why you are coming to mediation.HOW WOULD YOU LIKE YOUR APPOINTMENT TO TAKE PLACE?Meeting methodFace-to-faceOnline video appointmentNo preferenceAt which location?*We can routinely offer face to face appointments in our main office in Doncaster, Newark and Lincoln. If you need a face to face appointment in another location we will try to arrange this.DoncasterNewarkLincolnABOUT YOUFirst Name*Surname*Address Line 1*Address Line 2City / Town*County*Post Code*Contact Number*Email* Date of Birth*What is your National Insurance number?Occupation*Ethnic origin :*Prefer not to sayWhite BritishWhite IrishBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British OtherAsian or British Asian IndianAsian or British Asian PakistaniAsian or British Asian BangladeshiChineseMixed White & Black CaribbeanMixed White & Black AfricanMixed White & AsianMixed OtherWhite OtherAsian or British Asian OtherGypsy/TravellerPreferred contact method:* Phone Email Text Would you like us to call you to talk about your case?YesNoWhat time should we call?Before 9amBetween 9am & 3pmBetween 3pm & 7pmWill you need support coming to or taking part in your mediation?NoYesWhat is the name of the person you would like to support you?*Please give details of the support required:When is the best time to make your appointment?All appointment will take between 45-60 minutes. Make sure you will have time to take part.We will try to book your appointment to fit in with you. If you give us as much availability as possible we will have the best chance of offering you an appointment you can come to. Can you be available at late notice if we have a cancellation?YesNoDo you need notice?NoYes, 3-5 daysYes, 5-7 DaysMorning AppointmentsStart time between 9am and 1pmChose the dates you can take part in an appointment Afternoon AppointmentsStart time between 1pm and 2.30pmChose the dates you can take part in an appointment Late Afternoon AppointmentsStart time between 2.30pm and 5pmChose the dates you can take part in an appointment The best way to help us offer you an appointment which will work is for you to tick at least six dates when you can be available.ConfidentialityDoes the other person in your case know your email address?YesNoCan your email be shared with the other person in your case?YesNoYour SafetyHave the police ever been called by you or the other person in your case?*NoYesHas any action been taken by the police or courts against you or the other person in your case?*NoYesAre there any court orders in place which relate to you or the other person? This means bail conditions / a harassment order or an injunction*NoYesIs there a harassment order in place?NoYesIs there a non-molestation Order in place?NoYesAny other information you would like to provide?Your children’s safetyHave the children’s services or social workers been in contact with you or the other person about the children?*NoYesTerms & ConditionsDo you consent to us sending you updates about developments in mediation and quarterly newsletters?YesNoFamily Matters work with mediators who are working to a higher level or qualification, this means two mediators will be working on your case. Do you agree that this can take place ?*YesNoI have read and accept Family Matters Payments and Refunds policy and privacy policy*YesRead our privacy policy here Read our payments and refunds policy here Payment and Legal Aid fundingDo you want to apply for legal aid funding?No, I want to pay in full for my MIAM (£144)Yes, I want to apply for Legal Aid and I have received a payment from one of the benefits below in the last month (£20 deposit)Yes, I want to apply for Legal Aid but I have not received a payment from one of the benefits below in the last month (£144)*Qualifying benefits for legal aid: Universal Credit, Income-related Employment and Support Allowance, Income-based Jobseeker’s Allowance, Income Support, Pension Guarantee Credit. Are you working?NoYesPlease upload a photo or scan of your wage slip for the last month: Drop files here or Do you have a partner?NoYesAre they working?NoYesPlease upload a photo or scan of your partners wage slip for the last month: Drop files here or Do you have a house which is in your name or your name with another person?NoYesWhat is the value of the house?:What is the mortgage?:Please upload a bank statement showing your mortgage payment Drop files here or What is the total balance of your bank accounts (and your partner’s, if you have one)?Are you getting benefits (including Universal Credit)?NoYesPlease upload your JSA / ESA letter / A screen shot of your most recent UC payment:(It must clearly show your name, address and the date you have been paid) Drop files here or Where are you living?My own propertyRentingWith friends and familyPlease upload a photo or scan of your rental agreement Drop files here or Number of placesCost per placeSubtotal Price: £ 0.00 Quantity: Total amount (inc. VAT) £ 0.00 NameThis field is for validation purposes and should be left unchanged. At the end of this form, you will either be asked to pay a £20.00 deposit if you are applying for legal aid or to pay the full amount for your appointment. If you are not in a position to pay today, please contact our office on 01302 369688. Your Case If we have sent you an email or letter, please add your case number (this will be in the subject line of your email or at the top of your letter).Case NumberWhat would you like to talk about?Reason*Arrangements for my childrenArrangements for my financesArrangements about children and financesPlease tell us more about why you are coming to mediation.HOW WOULD YOU LIKE YOUR APPOINTMENT TO TAKE PLACE?Meeting methodFace-to-faceOnline video appointmentNo preferenceAt which location?*We can routinely offer face to face appointments in our main office in Doncaster, Newark and Lincoln. If you need a face to face appointment in another location we will try to arrange this.DoncasterNewarkLincolnABOUT YOUFirst Name*Surname*Address Line 1*Address Line 2City / Town*County*Post Code*Contact Number*Email* Date of Birth*What is your National Insurance number?Occupation*Ethnic origin :*Prefer not to sayWhite BritishWhite IrishBlack or Black British AfricanBlack or Black British CaribbeanBlack or Black British OtherAsian or British Asian IndianAsian or British Asian PakistaniAsian or British Asian BangladeshiChineseMixed White & Black CaribbeanMixed White & Black AfricanMixed White & AsianMixed OtherWhite OtherAsian or British Asian OtherGypsy/TravellerPreferred contact method:* Phone Email Text Would you like us to call you to talk about your case?YesNoWhat time should we call?Before 9amBetween 9am & 3pmBetween 3pm & 7pmWill you need support coming to or taking part in your mediation?NoYesWhat is the name of the person you would like to support you?*Please give details of the support required:When is the best time to make your appointment?All appointment will take between 45-60 minutes. Make sure you will have time to take part.We will try to book your appointment to fit in with you. If you give us as much availability as possible we will have the best chance of offering you an appointment you can come to. Can you be available at late notice if we have a cancellation?YesNoDo you need notice?NoYes, 3-5 daysYes, 5-7 DaysMorning AppointmentsStart time between 9am and 1pmChose the dates you can take part in an appointment Afternoon AppointmentsStart time between 1pm and 2.30pmChose the dates you can take part in an appointment Late Afternoon AppointmentsStart time between 2.30pm and 5pmChose the dates you can take part in an appointment The best way to help us offer you an appointment which will work is for you to tick at least six dates when you can be available.ConfidentialityDoes the other person in your case know your email address?YesNoCan your email be shared with the other person in your case?YesNoYour SafetyHave the police ever been called by you or the other person in your case?*NoYesHas any action been taken by the police or courts against you or the other person in your case?*NoYesAre there any court orders in place which relate to you or the other person? This means bail conditions / a harassment order or an injunction*NoYesIs there a harassment order in place?NoYesIs there a non-molestation Order in place?NoYesAny other information you would like to provide?Your children’s safetyHave the children’s services or social workers been in contact with you or the other person about the children?*NoYesTerms & ConditionsDo you consent to us sending you updates about developments in mediation and quarterly newsletters?YesNoFamily Matters work with mediators who are working to a higher level or qualification, this means two mediators will be working on your case. Do you agree that this can take place ?*YesNoI have read and accept Family Matters Payments and Refunds policy and privacy policy*YesRead our privacy policy here Read our payments and refunds policy here Payment and Legal Aid fundingDo you want to apply for legal aid funding?No, I want to pay in full for my MIAM (£144)Yes, I want to apply for Legal Aid and I have received a payment from one of the benefits below in the last month (£20 deposit)Yes, I want to apply for Legal Aid but I have not received a payment from one of the benefits below in the last month (£144)*Qualifying benefits for legal aid: Universal Credit, Income-related Employment and Support Allowance, Income-based Jobseeker’s Allowance, Income Support, Pension Guarantee Credit. Are you working?NoYesPlease upload a photo or scan of your wage slip for the last month: Drop files here or Do you have a partner?NoYesAre they working?NoYesPlease upload a photo or scan of your partners wage slip for the last month: Drop files here or Do you have a house which is in your name or your name with another person?NoYesWhat is the value of the house?:What is the mortgage?:Please upload a bank statement showing your mortgage payment Drop files here or What is the total balance of your bank accounts (and your partner’s, if you have one)?Are you getting benefits (including Universal Credit)?NoYesPlease upload your JSA / ESA letter / A screen shot of your most recent UC payment:(It must clearly show your name, address and the date you have been paid) Drop files here or Where are you living?My own propertyRentingWith friends and familyPlease upload a photo or scan of your rental agreement Drop files here or Number of placesCost per placeSubtotal Price: £ 0.00 Quantity: Total amount (inc. VAT) £ 0.00 PhoneThis field is for validation purposes and should be left unchanged.
