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7 Church Street
Wellington
Telford
TF1 1BX

Telephone:  01952 641291
Fax number:   01952 257519

Need some context to the form here:  Who Should be filling it in?

1. NAME OF PERSON SEEKING MEDIATION(required)

ADDRESS (required)

TELEPHONE NUMBER

PLEASE INDICATE IF YOU WISH THIS INFORMATION TO REMAIN CONFIDENTIAL FROM THE OTHER PARTY

DO YOU HAVE A SOLICITOR APPOINTED?

IF YES PLEASE PROVIDE DETAILS OF FIRM

SOLICITORS TELEPHONE NUMBER

NAME OF PERSON DEALING WITH MATTER


2. NAME OF OTHER PERSON (required)


RELATIONSHIP TO PERSON SEEKING MEDIATION

ADDRESS

TELEPHONE NUMBER


3. DOES THE OTHER PERSON HAVE A SOLICITOR

IF YES PLEASE PROVIDE DETAILS OF FIRM

SOLICITORS TELEPHONE NUMBER

NAME OF PERSON DEALING WITH MATTER


4. CHILDREN
Name and dates of birth


5. ISSUES TO MEDIATE IF KNOWN
ChildrenProperty and FinanceAll Issues


6. PLEASE INDICATE WHETHER YOU ARE CONTENT FOR US TO CONTACT THE OTHER PERSON NOW?


7. PLEASE INDICATE BELOW WHETHER THERE ARE ANY EXISTING COURT PROCEEDINGS OR ANY OTHER ISSUES/CIRCUMSTANCES THE MEDIATOR SHOULD BE MADE AWARE OF?


8. PLEASE INDICATE HOW YOU WERE REFERRED/HEARD OF OUR SERVICE

Your Email (required)