contact@kentfms.co.uk 01795 410457

Refer Yourself

Confidential Mediation Self-Referral Form

Please note that submission of this form will result in us opening a case for you and contacting you.  IF YOU ONLY REQUIRE INFORMATION AT THIS STAGE, OR TO SPEAK TO A MEMBER OF OUR STAFF, PLEASE COMPLETE OUR ENQUIRY FORM INSTEAD.   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’ button. After submitting the form, you should receive an automated message, followed by an email once the form has been received by the office. If you don’t, please ring the above number to check your referral has been received.

 

    YesNo
    Childs name (including surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    YesNo
    ResidenceContactFinancial / PropertySeparation/Divorce (e.g. timing, talking to children)Other Matters (please specify):
    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.
    Please click here to view the form and give your consent for us to hold your personal information confidentially on file for a maximum of 6 years. You will also be giving your consent for us to periodically email you information about the family related services that we provide. Click here to view our Data Protection Policy. If you require further assistance please ring 01795 410457 where our admin team will be able to help.

    Having trouble submitting the referral, or have any questions for us? Click here to contact us or call Kent Family Mediation’s main office on 01795 410457.

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