Solicitor Referral

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

 

 

 

 

CONFIDENTIAL MEDIATION SOLICITOR REFERRAL FORM

PLEASE COMPLETE THIS FORM AS FULLY AS POSSIBLE AND REMEMBER TO ENTER THE SPAM FILTER CODE BEFORE SELECTING THE SUBMIT BUTTON AT THE BOTTOM OF THE SCREEN TO SEND THE FORM TO US. AFTER SUBMITTING THE FORM, YOU SHOULD RECEIVE AN AUTOMATED MESSAGE, FOLLOWED BY AN EMAIL FROM THE OFFICE ONCE THEY HAVE RECEIVED THE FORM. 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

Sr.No Children’s Names (inc. Surname) Date of Birth: Living With:
1  
2  
3  
4  
5  
6  

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:

NB
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.

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




Can't read the image? click here to refresh