Mediation Referral Form
Referral Source
*
Social Care
Education
Voluntary Sector
Self-referral
Other
Date
*
/
Day
/
Month
Year
Date
Referrer's Name
*
First Name
Last Name
Referrer Email:
*
example@example.com
Contact No.
*
-
Phone Number
Team/Department Details:
Team/Department Name:
*
Team/Department Manager:
*
Team/Department Manager Contact Number
*
-
Area Code
Phone Number
Team/Department Admin Details
Team Admin Name
First Name
Last Name
Team Admin Email
example@example.com
Team Admin Contact Number
-
Area Code
Phone Number
CANCEL
CONTINUE
Have you discussed mediation with the persons concerned, and gained consent from ALL of them for the referral to be made to Oak Community Services (Y/N)
*
YES
NO
Please select Yes or No * We can only accept referrals where informed consent has been gained by all parties. Please contact the service if you need to discuss this further
Mediation Categories - reason(s) for mediation referral
*
Divorce and separation - This is chargeable/or via legal aid/or government voucher scheme - ASK THEM TO SELF REFER VIA THE WEBSITE
Child arrangements -This is chargeable/or via legal aid/or government voucher scheme - ASK THEM TO SELF REFER VIA THE WEBSITE
Conflict between separated parents (not part of/going to be part of private proceedings)
Conflict between parents living together
Contact issues (not part of/going to be part of private proceedings)
Parenting issues
Conflict between siblings
Conflict between children and adults
Conflict between wider family members
Other reason
If you have selected 'Other reason' please briefly outline:
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People Details:
*Please enter details of the people involved in the mediation:
Please enter the 'referred' people details below by adding the first person then clicking 'Add next person':
Please give a brief overview of why children's services are involved?
Main reasons for Mediation?
*
Please give details of why mediation is required
If the participants are hesitant or unsure about mediation, please outline any issues you aware of:
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Please detail any communication Needs:
Family Issue(s):
Yes/No
Give brief details of the person affected by this issue (include names)
Domestic Abuse
Yes
No
Neuro-Diversity (ND)
Yes
No
Mental Health
Yes
No
Alcohol/Drugs issues
Yes
No
Other
Yes
No
Risk Assessment
Please include any information the mediator needs to be aware of:
Is there a history of physical assault or verbal aggression between the people referred or anyone connected to them (Y/N)
*
YES
NO
Please select
If Yes, please give full details including names
Is there a history of physical assault or verbal aggression by people referred or anyone connected to them on professionals (Y/N)
*
YES
NO
Please select
If Yes, please give full details including names
Is it safe for professionals to visit alone? (Y/N)
*
YES
NO
Please select
Submit
Any other identified risks?
Briefly details any additional information related to any possible risks involved
Should be Empty: