Family Mediation Referral Form

Family Law Partnership
Referral Type

Are you a...


Please complete the following form on behalf of your client. We will contact your client to arrange an appointment.
Please complete the following form. We will contact you to arrange an appointment.
Your Details
Your name:
Job title:
Your firm's name:
Address:
DX number:
Telephone number:
Fax number:
Your reference:
Your Client's DetailsYour Details
Name:
Address:
Telephone:
Date of birth:
Partner/Former Partner's Details
Name:
Address:
Telephone:
Solicitor's name:
Address:
DX number:
Telephone number:
Fax number:
Reference:
Children's Details
Name Age/DOB Gender Whom living with
Details for Mediation

Is this referral under Section 29 of the Family Law Act?

Is this a referral under the Pre-action Protocol?

Have any Court proceedings commenced?

If so, what proceedings, in which Court and what stage has been reached?

Type of Mediation sought:

Has there been any history (alleged or actual) of violence, harassment, intimidation or child protection?