Mediation: Referral Form

Please note this document would be disclosable should either party request to see the information held about them.

Company Name*

Address (where mediation will take place)*

Street Address

Address (continued)

Post Code

Client Name (who the mediator should liaise with throughout the mediation process. Not one of the parties involved)*

First NameLast Name

Client Role*

Client Contact Number*

Preferably Mobile Number

Client Email*

Details of the parties who will be involved in the mediation

YesNoNot applicable

Do any of the above parties have any restrictions or need any adjustments to bring their best selves to the mediation?*

Please provide details of the restrictions or adjustments required*

Please ensure you confirm which party / parties these apply to

Please provide an overview of the issues between the parties*

What would be your preferred outcome of the mediation?*

In order to help with the allocation of a mediator, please enter as many dates as possible when all parties are available for the mediation*

PLEASE NOTE: as the client you will need to provide availability, and until we have these we are unable to allocate a mediator. The time required is half a day per person (eg three parties requires 1.5 days). Please try to give at least two options.

Are there any time restrictions for either party on the dates identified above? *

Please note a 'whole day' for us is normally classed as 8 hours

Who will be the main contact for the mediator at the venue?*

If this is not you please provide their name and contact number

PLANNING FOR THE MEDIATION

In order to ensure that logistics of the mediation run as smoothly as possible, below are the basic requirements to prepare for the mediation:-

Ensuring Employees Are Aware
Please ensure that each party has verbally agreed to the mediation, and they are expecting to hear from us, as we will make contact with them once we have received this form and our signed terms.

Room Requirements (for in-person mediations only)
Please arrange suitable rooms for the mediation dates. As far as possible, the following should apply:-

2-party mediation – two rooms minimum (three if available)
3-party (or more) mediation – three rooms minimum (four if available)

All rooms should be booked and available for the full duration of the mediation.

One of the rooms should be large enough to comfortably seat the full number of people attending, including the mediator. This room should also have projection facilities if at all possible.

Rooms for the parties should not be directly together (unless heavily soundproofed and checked). A room for the mediator inbetween is fine. Please also give consideration to the practicalities of the mediator moving between rooms, eg several flights of stairs or long distances will detract from the time available with parties.

Rooms should not be situated where either party could be made to feel uncomfortable (consider if they get upset, and any ‘gossip’ which may be created by people seeing them sat in rooms and the mediator going between them).

Where possible, rooms should contain the following equipment:-

Table and chairs (a round table is perfect but not essential)
Flipchart and flipchart pens
Tissues
Water and glasses
Notepaper and pens
Projection capability (one room only)

Contacting you if required

As the client, it's useful if you or a deputy can be ‘on call’ if possible via your mobile should the mediator need to contact you during the mediation.

AGREEMENT

By submitting this form, I agree:-

The parties entered into this form have agreed to mediation and are expecting to hear from Pragmatism.
All parties named are able to free up the full day for all dates entered.
The cost of mediation is per party, and each party named in this document will be charged at £725 + VAT excluding expenses (full terms to be signed on a separate document).
I have read and understand the above requirements for rooms, etc and that we are responsible for arranging the venue, the required number of rooms and covering costs where applicable.
Pragmatism also require separate business terms to be signed in order to progress with the mediation. Nothing can be progressed until both documents have been received.

Client Signature*

To confirm you're human and not a bot please draw along the line below (start at the dot)*

Mediation Referral Form