All Families Mediation - Client Information Form
Please fill in the client information form and on submission you will be redirected to another page to book your appointment.
Required fields are
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Your Personal Details
Your Title:
Mr
Mrs
Miss
Ms
First Name:
Last Name:
Email
*
:
Date of Birth:
Address:
United Kingdom
Tel / Mobile:
National Insurance No:
Occupation:
Best way to contact you:
Background Information:
Details of Former Partner or the Person You Wish to Mediate With
Title:
Mr
Mrs
Miss
Ms
Full Name:
Date of Birth:
Address:
United Kingdom
Email:
Tel/Mobile No:
Date Started Living Together:
Date of Separation:
Date of Marriage/Civil Partnership:
Date of Decree Nisi (Conditional Order):
Date of Decree Absolute (Final Order):
Are you currently involved in divorce, ending a civil partnership or child/ren proceedings?
Yes
No
Are you consulting a solicitor? If so, please give us their name, address, and telephone number:
If yes, what stage have they reached?
IMPORTANT: Have there been any incidents of Domestic Abuse:
Details of Children and Other Dependants
Child's Name:
Date of Birth:
Age:
Gender:
Male
Female
Any Special Needs:
Remove Child
Add Another Child
With whom are the children currently living? Please briefly outline the current arrangements for the children:
If you are separated from the other parent, are the children in contact with both parents?
Do you have Parental Responsibility for your children?
Yes
No
Not Sure
Is Parental Responsibility an issue between you and your partner/former partner?
Yes
No
Outline of issues you wish to discuss:
Your children:
Yes
No
Not Sure
Your money/property:
Yes
No
Not Sure
Divorce/separation:
Yes
No
Not Sure