REFERRAL FORM

The Bastows Divorce Mediaiton Family Mediation Information Form

This form is approved by the Family Mediators Association (FMA)and Resolution (formerly the Solicitors Family Law Association)for use by independent professional mediators who mediate as members of either organisation.

Please furnish the following preliminary information BEFORE the initial meeting. Please note that information furnished in this form may be shared with your husband/wife/partner (except an address or telephone number you may wish to keep private).
See Section 8 below.

( * required fields )

1. Your personal details

* Full name:
* Home address:
* Post code:

Date of birth:
Tel:
Fax:
* E-mail:
* Mobile:

At which address is it most appropriate for us to contact you?

How did you hear about The Bastows Divorce Mediaiton? (If we were recommended to you,it is always helpful for us to know by whom)

2. Relationship information

Date of marriage:

Date of start of any cohabitation:

If separated, date of separation

If living together, do you wish to consider separation?

Do you think that the relationship has broken down permanently?

Have you and your husband/wife discussed divorce?

If so, have you reached any agreement about divorce?

3. Children

Please give the following information concerning any children you and/or your husband/wife/partner may have:

1st Child:
Name:
Date of birth:
If relevant, current place of education:
Any special needs?

2nd Child:
Name:
Date of birth:
If relevant, current place of education:
Any special needs?

3rd Child:
Name:
Date of birth:
If relevant, current place of education:
Any special needs?

4th Child:
Name:
Date of birth:
If relevant, current place of education:
Any special needs?

Please continue below if there are five or more children, or if there are any other dependants.

With whom are the children currently living?

If you are separated from the other parent, do the children have contact with him/her?

If you are separated, does each child have their own bedroom in each home?

How many bedrooms are there in each home?

Do you have Parental Responsibility for the children?	Yes No Not sure
Is Parental Responsibility an issue?	Yes No Not sure

Are the children aware of the situation between you and your husband/wife/partner?

4. Other dependants

Please give the following information concerning any other dependants/people for whom you have care:

Name/s:

Any special needs?

5. Preliminary financial outline

The following preliminary information is requested. If financial issues are to be considered,a detailed financial form will in due course be furnished for completion.

The property where you live:

Address (if different from home address in Question 1)

Is this the property where you and your husband/wife/partner live or lived together?

Is it rented or owned?

Rented

Owned

In whose name is it?

Joint

Sole

Whose sole name?

If owned, estimated current value

and mortgage balance

Employment:

What is your occupation?

Current salary (gross)

If employed, name of employer

If self-employed or in partnership, estimate of current annual earnings

To what date are accounts available?

Other sources of income:

Do you have any other sources of income? If so, estimated amount

and source

(No further details required at this stage.)

6. Professional representation and support

Are you represented by a solicitor? If so,what is his/her name and address?

Name:
Address:
Telephone:
Email address:

Have you had any counselling or therapy relevant to the relationship problems? If so, from whom? Was it individual, as a couple, or as a family?

Are you still having counselling or therapy?

Would you like more information about counselling, life coaching and well-being support?

Have any other professional services been involved with your family e.g. Social Services?If so, please indicate when and where

7. Legal proceedings

Have any court proceedings started? If so, what proceedings, in what court, and what stage has been reached?

Is there a pending hearing date for any proceedings? If so, what is it?

Has a Child Support Assessment or maintenance order been sought or made in relation to any child? If so, please give details

Has an order been made, sought or threatened to protect any member of the family or their property? If so, please give details

8. Confidentiality

Do you want an address or telephone number kept confidential? If so, please tick Yes

Note that this form may be copied to your husband/wife/partner or the information shared. If you do not want this done at this stage, please tick

9. Outline of issues for discussion

Might you want to address or receive information on any of the following? (but this indication will not limit the issues that can be discussed in the mediation):

Future of the relationship	Yes	No	Not sure
Arrangements for separation	Yes	No	Not sure
Review of existing agreement or order	Yes	No	Not sure
Any question of behaviour, threat or abuse	Yes	No	Not sure
Parental responsibility for children	Yes	No	Not sure
Any other issues concerning children	Yes	No	Not sure
Financial/property issues	Yes	No	Not sure
Meetings are ordinarily held with both parties together. Does this create any concerns for you?	Yes	No	Not sure
Do you feel able to discuss this openly?	Yes	No	Not sure

10. Your aims in mediation

Please would you say what your aims are in coming to mediation. We appreciate that you may need to know more from the mediator(s), but it would help to have some preliminary idea of what you hope to achieve in broad terms,not in detail. Please do not provide information or send copies of correspondence that cannot be mentioned in discussion with you both or copied to one another. (This does not apply to a private address or telephone number if you wish to keep this confidential from your partner/former partner – see Section 8 above.)

Signed *
Date	Tuesday 29th of May 2012

( * required fields )

Please contact us if you would like advice or further information on divorce or any related matter:
E-MAIL

0845 680 6045

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