Solicitor Referral Form

Confidential Mediation Solicitor Referral Form

Please complete this form as fully as possible.

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.

Name of person referring* Name of solicitors* Address Telephone number* Email address*

Your clients name* Address* Postcode* Home telephone* Mobile telephone Work telephone Email address*

Respondants name* Address Postcode Home telephone Mobile telephone Work telephone Email

Name of respondants solicitor Address Telephone

Children

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

Any other children involved? YesNo

Date of marriage

Date of separation

Date of Decree Nist

Date of Decree Absolute

Issues for medication (please select) ResidenceContactFinancial / PropertySeparation/Divorce (e.g. timing, talking to children)Other Matters (please specify): Brief summary of situation including any concerns about Domestic Abuse, and any known contact with other agencies, e.g. Social Services: Do 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.

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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