solicitors' referral form

If you would like to refer clients to us, you can do this on line by completing this form.

All the information you supply will be treated with absolute confidentiality and will not be passed beyond our mediation team or discussed with any other parties without your agreement.
* (asterisk) indicates required fields.

1) Your details
* Your full name
* Name of firm
Your Address
Postcode
Your direct phone number
Your fax number
* Your email address
DX Number
Reference

2) Your client's details
Client's name
Client's address
Postcode
Client's DAYTIME phone number
Their email address (if known)
3) Details of other party
Other party's full name
Other party's Address
Postcode
Other party's DAYTIME
phone number
Other party's
email address (if known)
4) If other party represented by solicitors, solicitor details:
Contact at other party's solicitors
Address of other party's solicitors
Postcode
Other party's solicitor's direct phone number
Other party's solicitor's
fax number
Other party's solicitor's
email address
4) Please indicate the following:
Is this family or civil mediation?
 Family   or Civil
If family does it include:
children finance both
Whether your client or the other party are likely to be eligible for publicly funded mediation:
YES NO
May we add your email address to our list for possible future information mailings?
 YES NO