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) and we will contact you to arrange this.
Data Protection
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.
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.
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 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

Conclusion
Thank you for completing the referral form, please press submit to send the form. Once we receive it we will contact you to arrange your Mediation Information and Assessment Meeting (MIAM) as soon as possible - we will do this by email within two working days. If you are unable to correspond by email please contact us on 0800 058 4303. The following resources may also be helpful for you in the meantime:

- What is a Mediation Information and Assessment Meeting (MIAM)?

- Ten Myths Around Mediation

- What if my ex won’t mediate?

- How do mediators help you to find solutions?
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