Mediation Intake Form

Mediation Intake Form
The Mediation Intake form takes about 5 minutes to complete and provides your Mediator with some basic case and background information for the purposes of administration and preparation. The information collected is treated in the strictist of confidence and is not shared with the other party/s to your Mediation. Should you have any questions or require any assistance, please do not hesitate to call our team on 1300 164 164 or email us at admin@separationsolutions.com.au
Please select the option that best describes you, the person completing this form.*

I am a Lawyer representing a clientI am an individual representing myselfI am an individual with legal representation
Your Email address *
example@example.com
Mailing list

Yes, I would like to be added to the mailing list so that if an earlier date becomes available I will be notified?
Your Mediator*
Please select the Mediator that has been booked for your Mediation.

Your Details (Lawyer)

Please provide the below information about you as the Legal Representative.
Firm name*
Your name*

PrefixFirst NameLast Name
Other email addresses
Please provide any other office email addresses you would like us to include in our communications to you. Please separate multiple addresses with a comma: example@example.com, another@example.com
Your phone number*
Your Client's Details

Please provide the below information about your client.
Your client's name*

PrefixFirst NameLast Name
Client's DOB or age*
Client's occupation *
Client's Email address*
example@example.com IMPORTANT: Your client's email address will only be used for the distribution of the Mediation Agreement via DocuSign and Post Mediation Feedback Form. It will not be used for any other purpose nor will it be shared with the other party/s unless specifically instructed to do so.

Your Details (Individual)

Please provide the below information about you as the individual representing themself.
Your name*

PrefixFirst NameLast Name
Your age or DOB*
Your occupation*
Your phone number*

Your Details (Client)

Please provide the below information about you as a Client who has legal representation.
Your Name*

PrefixFirst NameLast Name
Your age or DOB*
Your occupation*
Your phone number*
Your Lawyer's Details

Please provide the below information about your legal representative.
Law firm name*
Lawyer's name*

PrefixFirst NameLast Name
Lawyer's Email*
example@example.com
Lawyer's phone number*

Your Details (Lawyer)