Refer Yourself for Mediation and making an application for legal

 1 London Road, Sittingbourne, Kent, ME10 1NQ
Tel:  01795 410457
Fax: 01795 438943




 Please note that submission of this form will result in us contacting you. Please give as much information as possible in the form below, fill in the spam code box correctly and ensure that you click the ‘Submit’ buttonAfter submitting the form, you should receive an automated message, followed by an email once the form has been recieved by the office. If you don’t, please ring the above number to check your referral has been received. 


Note: Please ensure you have cookies enabled / not blocked as they are required to submit this form
You must agree to the above consent statement to enable this form.

Have you mediated with Kent Family Mediation before? YES NO

Sr.No Children’s Names (inc. Surname) Date of Birth: Who do they live with?

Any other children involved? (Please select) YES NO
Please give brief details below.





Issues for Mediation (please select)

Brief summary of situation including any concerns about Domestic Abuse, and any known contact with other agencies, e.g. Social Services:

Does either of the above clients suffer from any disability or have any special needs? If yes, please give details below:

Are there any non-molestation, court orders or bail conditions in place?

Kent Family Mediation Service will be able to assess the eligibility of clients for Legal Services Commission payment of mediation fees and any payment will be made directly to the Service.

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