Pax Mediation - Referral Form

Referral Form
Introduction
Family mediation is a process in which an independent, professionally trained mediator helps you work out arrangements for your children and/or finances following separation. Mediation can also be helpful when arrangements you've made before need to change, particularly as your children grow up. Mediation helps you stay in control. The mediator will help you to find a solution that works for you both and will explain what needs to happen to make an agreement between you legally binding. The process is less stressful and significantly quicker than going to court and can save you money. Legal aid is also available if you are financially eligible.

You can use this form to provide us with your contact details to begin the mediation process. Or you can contact us to request an alternative format.

Once we have received a completed form, we can arrange a Mediation Information and Assessment Meeting (MIAM) for you.
Data Protection (GDPR)
By proceeding and submitting this form you consent to Pax Mediation collecting and using certain personal information to carry out our work of inviting you to and conducting mediations.*

Yes

Your Contact Details
Your Name*

First NameLast Name
Your Date of Birth

DayMonthYear
Your Address

County
Your Contact Number
Please enter a valid phone number. Do not include +44.
Your Email*
example@example.com
Have you instructed a solicitor?

NoYes
Your Solicitor's Contact Details

Other Parties Contact Details
Their Name*

First NameLast Name
Their Date of Birth

DayMonthYear
Their Address

County
Their Contact Number
Please enter a valid phone number. Do not include +44.
Their Email
example@example.com
Have they instructed a solicitor?

NoYes
Their Solicitor's Contact Details

Issue(s) for Mediation
What are the issues for mediation?

Child ArrangementsProperty or FinancesBothOther

Your Relationship to the Children
The Other Parties Relationship to the Children

Standard Questions
Are there any professionals currently involved? (e.g. Social Services or the Police)?
Leave blank if not applicable
Are there any past or current court orders or injunctions between yourself and the other party?
Leave blank if not applicable
Do you have any special requirements (e.g. wheelchair access, interpreter)?
Leave blank if not applicable
Is there any other information or details of which you think we should be aware?
Leave blank if not applicable
How did you hear about us?*

Does the other party know about the referral?

NoYes
Do you feel able to ask the other party to get in touch with us?

NoYes
Do you want to request a joint MIAM?

NoYes
Funding
Our mediation service is amongst the most cost-effective options available. You can find details about our charges here: https://www.paxmediation.co.uk/mediation-fees

If you proceed on a privately paying basis, we will send potential dates for an appointment upon receiving your referral.

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We are also one of the few providers in the UK contracted to provide mediation funded by Legal Aid. If you are eligible, mediation is FREE for you. The Legal Aid assessment for Family Mediation is means-based, and you can find more information here: https://www.gov.uk/legal-aid

If you proceed on a legally aided basis, we will send instructions on applying for legal aid upon receiving your referral. We will assess your eligibility ahead of your appointment and if you are not eligible you do not have to proceed.
How would you like to proceed?*

Privately PayingLegal Aid

Your Availability
Private Clients

Thank you for confirming that you will pay for the meeting. The next step is to arrange your Mediation Information and Assessment Meeting (MIAM).

So that we can offer an appointment as soon as possible that suits your needs please indicate whether you would prefer an online (ZOOM), face-to-face or online out of hours appointment.

Our charges are listed below:

Online (Zoom)	£130
Face-to-Face / In person	£150
Out of Hours (Zoom)	£200

Please note, we currently have greater availability for Online (ZOOM) appointments and we may be able to offer an appointment sooner if you attend this way.

Appointment Preference (select any that are suitable for you)*

Online (ZOOM)Face-to-Face / In personOut of Hours (ZOOM)
Face-to-Face / In person - Venue Preference (select any that are suitable for you)*

Newcastle Quayside, NE1 3DYGateshead Team Valley, NE11 0NQAshington, NE63 9JZSunderland Doxford Park, SR3 3XW

Conclusion
Now, please press submit to complete the referral form.
- If you have told us that you will pay for your meeting, we will contact you by email shortly to provide potential dates.
- If you have told us that you wish to apply for Legal Aid, we will re-direct you to the Legal Aid application form, and we will also send a copy of this to the email address that you provided.
Do check your junk and spam folders for our emails. If you are unable to correspond by email please contact us on 0800 058 4303.
Should be Empty:

	First Name	Surname	Gender	Date of Birth	Who do they live with?
Child 1
Child 2
Child 3
Child 4
Child 5

Referral Form

Introduction

Data Protection (GDPR)

Your Contact Details

Other Parties Contact Details

Issue(s) for Mediation

Standard Questions

Funding

Your Availability

Private Clients

Conclusion