Please complete the mediation self referral form below Your DetailsName*Email*Phone number*Your Solicitor's Details - If ApplicableNameOrganisationEmailPhone numberAre you happy for the other party to be contacted concerning mediation?* Yes No Do you wish to attend a separate Assessment Meeting with a recognised mediator before the other other party is contacted?* Yes No Other Party's DetailsName*Email*Phone numberOther Party's Solicitor's Details - If ApplicableNameOrganisationEmailPhone numberMarital Status Prior to Separation* Married Co-habiting Civil Partnership Other Concerns* Domestic Abuse Child Welfare Issues Not Applicable Mediation Service Required Child/Children Only Finances Only Child/Children & Finances Additional InformationUntitled* Tick to accept our privacy notice Explore our branches Nelsons Derby Tel: 01332 372372 View Office Nelsons Leicester Tel: 0116 222 6666 View Office Nelsons Nottingham Tel: 0115 958 6262 View Office
