Mediation Voucher Scheme Questionnaire & Consent Form The Ministry of Justice and Family Mediation Council are collecting information from participants to better understand users of the voucher scheme; information collected will be anonymised and held as set out in the scheme information provided to you.Your First Name*Your Surname*Your Email* Mediation service that applied for the voucher*If there was no mediation voucher, would you have pursued mediation?Rather not sayYesNoWhat is your ethnic group?Rather not sayWhite - English/Welsh/Scottish/Northern Irish/BritishWhite - IrishWhite - Gypsy or Irish TravellerNixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseBlack - CaribbeanBlack - AfricanBlack - BritishArabOtherPlease describe your ethnic backgroundHow would you describe your sexual orientation?Rather not sayHeterosexual/StraightGay/LesbianBisexualOther, please describePlease describe your sexual orientationWhat was your sex registered at birth?Rather not sayMaleFemaleIs the gender you identify with the same as your sex registered at birth?Rather not sayYesNo - FemaleNo - MaleNo - Other or non-binaryDo you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more?Rather not sayYesNoWhat is your religion or belief?Rather not sayNo religionChristian (including Church of England. Catholic. Protestant and all other Christian denominations)BuddhistHinduJewishMuslimSikhAny other religion, please describePlease describe your religion or beliefsWhat is your legal marital or registered civil partnership status?Rather not sayNever married and never registered in a civil partnershipMarriedIn a registered civil partnershipSeparated, but still legally marriedSeparated, but still legally in a civil partnershipFormerly in a civil partnership, which is now legally dissolvedSurviving partner from a civil partnershipWidowedAre you currently pregnant?Rather not sayYesNo Please Confirm: * I consent to my mediator applying for a contribution towards the cost of mediation from the Mediation Voucher Scheme which was launched on 26 March 2021 * I confirm that I have not made another application for a mediation voucher under the Scheme * I understand that my mediator will submit case information to the Family Mediation Council which will be used for research purposes * I understand that the Family Mediation Council will hold my data in accordance with its Privacy Notice for the Mediation Voucher Scheme which can be read here Signed:*Date: 14/09/2024Date* Date Format: DD slash MM slash YYYY
