Complete a Form Online

Client Form to arrange a Mediation Information & Assessment Meeting (MIAM) or Family Mediation

By completing this form we will spend less time during your initial appointment asking you questions and more time helping you consider your options. Completed forms are kept confidentially by Start Mediation Ltd and any information you provide on this form will not be shared with anyone else without your permission (and we will discuss any exception to this with you). By submitting your completed form, you consent to your data being collected and stored.

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Step 1 of 4 - Introduction

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This form can be saved after the completion of any page by clicking on 'Next'. This will save it so that you can come back and complete it later, but you must be using the same device and browser. Also, you must avoid clearing your browser's cache. After submitting it, a copy will automatically be sent to the email address you provide for yourself.

The content of this form will be treated confidentially. This means the information and data provided will not be disclosed to anyone else outside of Start Mediation Ltd unless you provide consent.

What do you want help with?*

Please select at least one of the following.

Separation, dissolution or divorce

Financial claims arising on dissolution or divorce

Parenting arrangements for children

Child support payments

Property claims arising out of a cohabitation

Grandparenting arrangements for children

Variation of existing court order

Other - please provide details in your answers to the further questions below

Your details

Name*

First Last

Primary phone number*

Mobile number, if different.

Email address*

NOTE: this is the address which a copy of this form will automatically be sent to.

Postal address*

Street Address Address Line 2 Town or City Post Code or ZIP Country

Date of birth*

DD slash MM slash YYYY

Occupation

Do you think you might qualify for legal aid?*

Yes

What is your total monthly net (after tax) income from the following: employment, self-employment; tax credits, child benefit, other state benefits, spousal maintenance; child support and any other source.*

What is the approximate value of any property you own, after deducting the value of any mortgage?*

What is the approximate value of your savings, jewellery, investments or valuable possessions?*

Do you think the person who you share a problem or dispute with might qualify for legal aid?*

Yes

Do you live with a spouse or partner?*

Yes

Please provide their total monthly net (after tax) income from the following: employment, self-employment; tax credits, child benefit, other state benefits, spousal maintenance; child support and any other source.*

Before mediation starts, you will need a MIAM (Mediation Information and Assessment Meeting) or suitability meeting with a mediator. These can be held at our consulting room in Ipswich or by a video call over the internet.*

On my own with you in Ipswich

On my own with you by video call

Do you have any disabilities or health concerns you would like us to know about?

Yes

Please provide details:

Details about the person you share a problem with or who you are in dispute with

Their name*

First Last

Are they aware that you want to meet with a mediator?*

Yes

Their date of birth (or age)*

Their occupation

Your relationship to them*

Are married and live together

Are married and have separated

Are married and are divorcing

Were married and have divorced

Are in a civil partnership and live together

Are in a civil partnership and have separated

Are in a civil partnership and are dissolving it

Were in a civil partnership which has been dissolved

Are living together

Were living together

Have never lived together

Other

Please specify :

Did you live together before you got married or entered civil partnership?*

Yes

When did you start living together?*

When did you marry or enter into a civil partnership?*

When did you separate?*

Have you discussed separation, dissolution or divorce?*

Yes

Are you interested in reconciliation?*

Yes

Who made the decision to end the relationship?*

Other person

Both of us together

Who started the divorce or dissolution proceedings?*

Other person

Both of us together

When did the divorce start?*

When was the divorce or dissolution finalised?*

Their postal address is required, but if you do not have it, please add YYY to each line.*

Street Address Address Line 2 Town or City State / Province / Region Post Code or ZIP Country

Their email address

Their main telephone number

How would you describe their health?

Are there of any religious, ethnic or cultural issues which could be relevant?

Yes

Please provide details

Children under 18 or still in full-time education or still dependant for other reasons, and other dependants

Do you have a child under 18 or still in full-time education or still dependant for other reasons?*

Yes

Child 1

Name

First Last

Date of birth

DD slash MM slash YYYY

Living with

Other parent

Other

Please specify :

Do you have Parental Responsibility?

Any special needs?

How would you describe their health?

Is the other person a parent to this child?

Yes

Do you have a second child?

Yes

Child 2

Name

First Last

Date of birth

DD slash MM slash YYYY

Living with

Other parent

Other

Please specify :

Do you have Parental Responsibility?

Any special needs?

How would you describe their health?

Is the other person a parent to this child?

Yes

Do you have a third child?

Yes

Child 3

Name

First Last

Date of birth

DD slash MM slash YYYY

Living with

Other parent

Other

Please specify :

Do you have Parental Responsibility?

Any special needs?

How would you describe their health?

Is the other person a parent to this child?

Yes

Do you have a fourth child?

Yes

Child 4

Name

First Last

Date of birth

DD slash MM slash YYYY

Living with

Other parent

Other

Please specify :

Do you have Parental Responsibility?

Any special needs?

How would you describe their health?

Is the other person a parent to this child?

Yes

Do you have a fifth child?

Yes

Child 5

Name

First Last

Date of birth

DD slash MM slash YYYY

Living with

Other parent

Other

Please specify :

Do you have Parental Responsibility?

Any special needs?

How would you describe their health?

Is the other person a parent to this child?

Yes

Do you have a dependent who is not a child, or do you live with someone who you have not already mentioned?

Yes

Please provide details

What do you and other parent do best as parents?

What are your hopes for your relationship with the other person?*

Do you have any concerns about any child's emotional or physical safety with you or the other person?

Yes

Please provide details

Has a child ever witnessed any incident of physical, verbal or emotional abuse?

Yes

Please provide details.

What effect do you think your relationship with the other person has on your child or children?*

A great deal

Some

Couldn't say

A little

None at all

Do any of the following apply to you or your relationship with the other person?

Have there been any incidents of drug or alcohol abuse?*

Yes

Please provide the details:

Do either you or the other person suffer from mental or physical health problems?*

Yes

Please provide the details:

Have you or the other person any reason to be fearful of each other, ever threatened to hurt each other, hit or used any other type of physical force towards each other, or emotionally, culturally or sexually abused each other? Have you or the other person called the police, requested a protection order or sought help as a result of abuse by the other person?*

Yes

Please provide the details:

The problem or dispute you want to discuss

Please describe the problem that exists between you and the other person.*

What are the obstacles, if any, to you and the other person reaching your own agreement?*

Judges expect parents or spouses to attempt to solve their problems through mediation before making a court application. Are you willing to mediate?*

Yes

Please give your reasons.

Judges expect potential respondents to also meet with a mediator before any application to court is made. Do you believe the other person might be willing to mediate?*

Yes

Please give your reasons.

Please use this space to tell us about anything else relevant to this problem or dispute.

Professional representation

Do you have a lawyer?

Yes

Lawyer's name

First Last

Name of law firm

Lawyer's email address

Lawyer's phone number

Where did you first hear about us?*

You contacted me.

Searched Google and saw your name.

Searched Google and saw your ad.

Searched Bing and saw your name.

Searched Bing and saw your ad.

Recommended by a lawyer.

Recommended by a friend.

Found your name on the Family Mediation Council website.

Other

Please specify :

Date*

DD slash MM slash YYYY

Complete a Form Online

Client Form to arrange a Mediation Information & Assessment Meeting (MIAM) or Family Mediation

Your details

Details about the person you share a problem with or who you are in dispute with

Children under 18 or still in full-time education or still dependant for other reasons, and other dependants

Child 1

Child 2

Child 3

Child 4

Child 5

Do any of the following apply to you or your relationship with the other person?

The problem or dispute you want to discuss

Professional representation

Success!