Mediation Self Referral Form


1. Full Name *


2. Title


3. Date of Birth


4. Address including postcode *


5. Telephone *


6. Email *


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


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. *


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?

Powered by SmartSurvey