Tel: 0845 230 9818 or
023 9243 3388

Request A Mediation Appointment

About You

Title: Mr Mrs Miss Ms Other Please Specify:

First Name(s):

Surname:

Address:

Postcode:

Telephone:
(Best number to contact you)

Email Address:

Date of birth:

If you have a solicitor please give details:

About the Other Person

Title: Mr Mrs Miss Ms Other Please Specify:

First Name(s):

Surname:

Address:

Postcode:

Telephone:
(Best number to contact you)

Email Address:

Date of birth:

If you have a solicitor please give details:

Date of Marriage or when started living together:

Date of Separation:

Please give details of any Children below:

Children's Name	Date of Birth	Living With	Are there any health matters?

Issues for mediation - please indicate all that apply:

Contact Residence of children Finance/property
Parental Responsibility Other (please detail)

Please indicate all the venues where you could attend for the initial appointment:

Portsmouth (Cosham) Southampton Winchester Newport(IOW) Basingstoke Gosport Andover Salisbury Ryde(IOW)

Would you like an individual first appointment with the mediator or one jointly with the other person? (In our experience it is better to have individual appointments where there are contact or residence issues.)

Individual Joint

Do we have your permission to contact the other person now? Yes No

Please indicate availability (as much as possible please):

Days Times

Is this a joint application agreed with the other person? Yes No

Verification Code: