Mediation Referral Form Mediation Referral Form Person ReferredName Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last DOB: Address Street Address ZIP / Postal Code Home Tel NumberMobile NumberEmail Eligible for Legal Aid?YesNoSpecial NeedsNoPhysicalLearning DifficultiesMental HealthIf yes, please state what facilities or assistance may be needed:Referred Person's Solicitor Details First Last Firm Name/Address Street Address ZIP / Postal Code ReferenceSolicitor's PhoneSolicitor's Email Other PersonName Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Last Other Person's DOB: Other Person's Address Street Address ZIP / Postal Code Other Person's Home Tel NumberOther Person's Mobile NumberOther Person's Email Is the Other Person Eligible for Legal Aid?YesNoOther Person's Special NeedsNoPhysicalLearning DifficultiesMental HealthIf yes, please state what facilities or assistance may be needed:Other Person's Solicitor Details First Last Firm Name/Address Street Address ZIP / Postal Code ReferenceSolicitor's PhoneSolicitor's Email Relationship DetailsDate of Cohabitation Date of Marriage Date of Separation Stage in Legal Proceedings Children’s DetailsPlease state the name, sex, DOB and who each child is living with.Is the other person aware of this referral?YesNoAreas for MediationAll issues – children & financialFinancialChildrenOutline of current situation: if necessaryIs there any objection to us contacting the other party at the outset?YesNoAre there any restrictions on us contacting the other party because of bail conditions/restraining orders/injunction orders?YesNoClient self-referral?YesNoIf yes, how did they hear about MKB Δ
