Mediation Referral Form

Information About Children

Child's Name:

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D.O.B.:

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Who They Live With:

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Child's Name:

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D.O.B.:

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Who They Live With:

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Child's Name:

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D.O.B.:

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Who They Live With:

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Child's Name:

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D.O.B.:

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Who They Live With:

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Child's Name:

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D.O.B.:

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Who They Live With:

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Child's Name:

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D.O.B.:

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Who They Live With:

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Issues to be discussed within mediation

Please select as appropriate

Children IssuesFinancial IssuesChildren and Financial Issues Invalid Input

ARE THERE SAFETY ISSUES OR ISSUES OF DOMESTIC VIOLENCE?

YesNo Invalid Input

IF YES PLEASE PROVIDE DETAILS AND CONFIRM WHETHER ANY ORDERS ARE IN PLACE: IF THERE ARE COURT ORDERS IN PLACE, IS THERE ANY ORDER PREVENTING US FROM CONTACTING THE OTHER PARTY ON YOUR BEHALF TO INVITE THEM TO MEDIATION? (If unsure please write ‘unsure’)

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ARE THERE PREVIOUS OR ONGOING COURT PROCEEDINGS (INCLUDING DIVORCE PROCEEDINGS)?

YesNo Invalid Input

IF YES PLEASE PROVIDE DETAILS AND CONFIRM WHETHER ANY ORDERS ARE IN PLACE:

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DOES YOUR CLIENT REQUIRE HELP WITH ACCESS OR HAVE ANY SPECIAL REQUIREMENTS?

YesNo Invalid Input

IF YES PLEASE PROVIDE DETAILS:

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IS YOUR CLIENT OR THE OTHER PARTY LIKELY TO BE ELIGBLE FOR LEGAL AID?

YesNo Invalid Input