Mediation Self Referral Form

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1. Full Name *

2. Title

Ms
Mrs
Miss
Mr

3. Date of Birth

	DD/MM/YYYY

4. Address including postcode *

5. Telephone *

6. Email *

7. Would you like to be assessed for Legal Aid? *

Yes - I receive Universal Credit
Yes - I receive Income Support
Yes - Yes I receive Income based JSA or Income based ESA
Yes - I don't receive one of the benefits listed but would like to be assessed
No

8. We are able to offer appointments online (via Zoom) or face-to-face at one of our offices. We will discuss this with you when we arrange your appointment but it would be helpful if you could let us know your preference. *

Online via Zoom
Face-to-face at one of our offices

9. The first step will be to arrange an individual Mediation Information and Assessment Meeting (MIAM). We will contact you to arrange the appointment but it's helpful to know if there are any days/times to avoid?

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