[email protected] 01795 410457

Refer Yourself

Confidential Mediation Self-Referral Form

 

 

PLEASE NOTE THAT SUBMISSION OF THIS FORM WILL RESULT IN US CONTACTING YOU TO INITIATE THE MEDIATION PROCESS.

 

IF YOU ONLY REQUIRE INFORMATION AT THIS STAGE PLEASE COMPLETE OUR ENQUIRY FORM AND A MEMBER OF THE TEAM WILL CONTACT YOU.

 

 

    YesNo
    Childs name (including surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    Childs name (inc. surname)
    Date of Birth
    Living with
    YesNo
    ResidenceContactFinancial / PropertySeparation/Divorce (e.g. timing, talking to children)Other Matters (please specify):
    Kent Family Mediation Service will be able to assess the eligibility of clients for Legal Services Commission payment of mediation fees and any payment will be made directly to the Service.
    Please click here to view the form and give your consent for us to hold your personal information confidentially on file for a maximum of 6 years. You will also be giving your consent for us to periodically email you information about the family related services that we provide. Click here to view our Data Protection Policy. If you require further assistance please ring 01795 410457 where our admin team will be able to help.

    If you are having problems with the referral form, or have any questions? Click here to contact us via our online form, or telephone 01795 410457.

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