Referral Form Wells Family Mediation Referral Form "*" indicates required fields Your Contact Details:Full Name*Home Address Line 1*Home Address Line 2Postcode*Telephone*Email* Mobile*OccupationDate of Birth DD slash MM slash YYYY Your Ex-PartnerFull Name*Home Address Line 1*Home Address Line 2PostcodeTelephone*This field is hidden when viewing the formEmail Mobile*OccupationDate of Birth DD slash MM slash YYYY Relationship InformationDate of Marriage/Civil Partnership (if applicable)This field is hidden when viewing the formDate of separation DD slash MM slash YYYY Date of Divorce Conditional Order/ Divorce Final Order (if applicable)Children of the familyPlease list names and ages, with date of births and current school, of any childrenProfessional RepresentationAre you consulting a solicitor?YesNoIf so, please give name and contact detailsIs your ex-partner consulting a solicitor?YesNoIf yes, please give name and contact details, if known to youReferralHow did you hear about WFM?Issues to be addressedPlease state briefly the issue or issues needing to be addressedI confirm that I understand that, WFM is holding personal information about myself for the purposes of mediation* I understand.Legal Aid is available for family mediation. We do not have a Legal Aid contract, if you feel you or your ex partner might qualify then do discuss this with us before your initial meeting. If you have any worries or concerns about mediation, please make sure you raise them when you meet the mediator on your own before mediation starts.EmailThis field is for validation purposes and should be left unchanged.
