Enter Your Full Name

Enter your Email Address

Enter Your Main Telephone Number

Enter Your Postal Address

What is your Date of Birth?

Have You Consulted a Solicitor? Have You Consulted a Solicitor? Yes No

Would you like your information kept confidential from your partner? Would you like your information kept confidential from your partner? Your Postal Address? Your Email Address? Your Telephone Number? None of the Above

Are You Involved in any Family Proceedings? Are You Involved in any Family Proceedings? Yes No

What Stage Have They Reached?

What are your Solicitor's details?

Have undertaken any relevant Counselling or therapy or involved any other professionals (i.e. Relate, Social Services)? Have undertaken any relevant Counselling or therapy or involved any other professionals (i.e. Relate, Social Services)? Yes No

Please give brief details of the other professionals

What is your relationship to the other person? What is your relationship to the other person? Are You Married? Are you cohabiting? Other?

What was the Date of your Marriage?

What was the Date you began Living Together?

What was the Date of your Separation?

What was the date of your Decree Nisi?

What was the date of your Decree Absolute?

Have You Remarried or Do You Intend to Do So? Have You Remarried or Do You Intend to Do So? Yes No

Are you Cohabiting with someone else or do you intend to do so? Are you Cohabiting with someone else or do you intend to do so? Yes No

Please indicate the nature of your relationship

Are there any issues of Protection, Violence, Safety or Abuse which we may need to address? Are there any issues of Protection, Violence, Safety or Abuse which we may need to address? Yes No

Do you want a Separation or Divorce? Do you want a Separation or Divorce? Yes No

Does your Partner want a Separation? Does your Partner want a Separation? Yes No

Do you have any dependent children? Do you have any dependent children? Yes No

How many Dependent Children Do you have? How many Dependent Children Do you have? 1 2 3 4 5 6

Child 1's Name and Date of Birth:

Child 2's Name and Date of Birth:

Child 3's Name and Date of Birth:

Child 4's Name and Date of Birth:

Child 5's Name and Date of Birth:

Child 6's Name and Date of Birth:

With whom are the children currently living?

Please outline the current arrangements for the children

If you are separated from the other parent, are the children in contact with both parents, or with any other persons?

Are the children aware of the situation?

Are there any child safety concerns? Are there any child safety concerns? Yes No Not Sure

What are the arrangements for financial support in relation to any of the children? What are the arrangements for financial support in relation to any of the children? Voluntary Maintenance Agreement? Child Maintenance Service Assessment? Court Order for Child Maintenance? Other?

Please set out child maintenance arrangements

Is child maintenance being paid? Is child maintenance being paid? Yes No

If so, how much and how often?

Do you have Parental Responsibility? Do you have Parental Responsibility? Yes No Not Sure

Is this an issue between you? Is this an issue between you? Yes No Not Sure

Do Finances Need to be Considered? Do Finances Need to be Considered? Yes No

What is the address of the family home?

Is the family home rented or owned? Is the family home rented or owned? Owned? Rented

Is the property owned jointly or solely and by whom?

What is the estimated current value?

What is the estimated mortgage balance?

Do you have any other assets? Do you have any other assets? Yes No

Estimated value of other assets?

What is your current employment?

What are your current total salary or earnings from work?

Do You Have any other Income? Do You Have any other Income? Yes No

What is the source of the other income and how much is it - no further details are required at this stage?

Full name of the other person?

Postal address of the other person?

Telephone number for the other person?

Other person's email address:

Please confirm how we can contact them by ticking all that apply Please confirm how we can contact them by ticking all that apply Can we telephone them? Can we email them? Can we write to them?

What do you want to resolve in mediation? What do you want to resolve in mediation? Property and Finance Children Arrangements Divorce or Separation Communication Issues Other

Please set out what you wish to bring to mediation

Please briefly describe what your goals are in mediation.

How did you hear about us? How did you hear about us? Word of Mouth Solicitor Website Advert Other

Please explain where

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