REFERRAL FORM CLIENT 1 DETAILS Client 1 - Name (Required) * First Name Last Name Address (Required) * Phone Number * Email * Date of Birth MM DD YYYY Relationship to Child CLIENT 2 DETAILS Client 2 Name First Name Last Name Address Client 2 Phone Client 2 Email Client 2 Date of Birth Client 2 MM DD YYYY Relationship to Child CHILD(REN)S DETAILS Childs Name First Name Last Name Childs Date of Birth MM DD YYYY Male or Female Male Female Child 2 Name First Name Last Name Child 2 Date of Birth MM DD YYYY Child 2 - Male or Female Male Female Child 3 Name First Name Last Name Child 3 Date of Birth MM DD YYYY Child 3 - Male or Female Male Female ISSUES FOR MEDIATION Please Tick - Child Issues Property & Finance All Issues Does the client(s) have any special requirements (e.g. Wheelchair access, interpreter, health issues)? Any other information or details of which you think we should be aware? Privacy note - Please note that by completing this referral form you are giving consent to Mediation Associates to hold limited personal information in order to enable you to get access to the mediation information and assessment process introduced by the Children and Families Act 2014, s 10). This information will be held securely and will only be used for the purpose of providing information or mediation and where appropriate securing legal aid. You can request your data be removed from our systems by contacting us in writing. Thank you!
