Book a fast easy MIAM

Please fill in as much information as possible to enable us to arrange a mediation information meeting (MIAM)

When you submit this form, it will not automatically collect your details like name and email address unless you provide it yourself.

Mediation Referral Form

Please provide as much information as possible to enable us to arrange a Mediation Information and Assessment Meeting (MIAM). Submitting this form will not automatically provide us with your name or contact details. Please enter these below.

Your Details

Please provide your own details below.

Full Name *

Date of Birth *

Address *

Postcode *

Telephone *

Email Address *

Other Party Details

Please provide as much information as possible about the other party.

Full Name *

Date of Birth

Address

Postcode

Telephone

Email Address

Mediation Issues

Which issues would you like to discuss in mediation? *

Children’s IssuesProperty and/or FinanceProperty, Finance and Children (All Issues)

Legal Information

Do you have a solicitor? *

YesNo

Solicitor’s Name

Solicitor’s Email Address

Solicitor’s Telephone Number

Children

Do you have any children? *

YesNo

First Child

Child’s Name

Child’s Date of Birth

Relationship to child

MotherFatherOther

Child lives with

MotherFatherOther

Add another child

Second Child

Child’s Name

Child’s Date of Birth

Relationship to child

MotherFatherOther

Child lives with

MotherFatherOther

Add a third child

Third Child

Child’s Name

Child’s Date of Birth

Relationship to child

MotherFatherOther

Child lives with

MotherFatherOther

Add a fourth child

Fourth Child

Child’s Name

Child’s Date of Birth

Relationship to child

MotherFatherOther

Child lives with

MotherFatherOther

How Did You Hear About Us?

Please select an answer *

If you selected “Other”, please provide details

Consent and Data Protection

Kent Family Mediation Service may assess whether clients are eligible for Legal Aid Agency payment of mediation fees. Any eligible payment will be made directly to the Service. We will hold the personal information provided through this referral securely and confidentially for up to six years, in accordance with our retention policy. Please read our Data Protection Policy. If you require assistance, please call our administration team on 01795 410457.

I confirm that I have read the Data Protection Policy and understand how my personal information will be used. *

I would like to receive occasional emails about family-related services provided by Kent Family Mediation Service.

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