Client Referral Form

NOTE : Please bring the completed form to your first appointment. Information given to us on the form and at any assessment meeting is confidential and will not be shared with any (ex-) partner unless you give us permission to do so. In particular, your contact details will not be disclosed. However, if we proceed into mediation, we will ask if this completed sheet can be shared with your (ex-) partner. Do telephone us if you have any queries.

Client Initial Information Form

Feel free to get in touch , our friendly team are here to help in any way we can.

I wish my Email and home address and telephone numbers to be kept confidential

Yes No

If you are consulting a Solicitor, Please State

Are there issues of abuse, protection, violence or safety, which we may need to address, either in relation to you or any children? If YES, please specify

Yes No

Are you aware of any potential involvement with the proceeds of crime or money laundering, however small? If YES, please specify

Yes No

Are there any reasons why you would not wish to be in the same room as your (ex-) partner? If YES, please specify.

Yes No

PLESE COMPLETE ONE OF THE FOLLOWING SECTIONS YOUR (EX-) PARTNER OR SPOUSE PLEASE PROVIDE THEIR INFORMATION

Do you think the marriage /relationship has broken down irretrievably?

Yes No

Are you seeking a permanent separation?

Yes No

or Divorce?

Yes No

Are you currently involved in divorce or other court proceedings?

Yes No

Are you Married?

Yes No

If no,

Were you married previously?

Yes No

IF THE OTHER PARTICIPANT IS SOMEONE OTHER THAN YOUR (EX-) PARTNER OR SPOUSE PLEASE PROVIDE THEIR INFORMATION

IF THERE ARE RELEVANT CHILDREN, PLEASE COMPLETE THE FOLLOWING, EVEN IF THEY ARE NOT THE SUBJECT OF ANY DISPUTE

Are the child/children aware of the situation ?

Yes No

If YES were both parents involved in speaking with the children?

Yes No

If your children are of age would you consent to them being part of the mediation process?

Yes No

If financial matters are to be considered, a detailed questionnaire will be provided after your first session. Meanwhile, some preliminary information would be helpful, but treated in confidence

PRELIMINARY FINACIAL OUTLINE

THE FAMILY HOME

EMPLOYMENT

Are you in full time employment?

Yes No

CONSENT

Please tick the appropriate box

I give my consent i do NOT give my consent

To FMA/FMC or representatives of the Legal Aid Agency auditors having access to my files as a part of any quality checks/inspection.

Your Signature

By adding your name and submitting this form online you are agreeeing to participate in the mediation process.

EQUAL OPPORTUNITIES MONITORING CODE

PLEASE TICK APPROPRIATE BOXES

Client Referral Form

Client Initial Information Form

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Contact info

0203 005 8824

info@spectruminc.co.uk

361 Barking Road, Plaistow, E13 8EE