CLIENT SELF REFERRAL
Office Use Only Wherever possible this form needs to be seen and completed by both parties’ Mediation cannot commence until this form has been completed in full and received by the centre Coordinator. All information will be treated in the strictest confidence.
Referral received Date of Pre-visit Date of first Mediation Dates Reviewed Contact Ended
Title Mr/Mrs/Ms/etc Surname First name(s) Relationship to each other Postal address and postcode
Tel No(s) Details of Solicitor acting for you in these matters (if you have one) Name, address, tel no If mediation goes ahead, your solicitor will be informed when it begins and when your cases with our Service closes.
Where/how did you hear about our Service? Details of children Name
Date of Birth
What issues are you seeking to resolve through mediation? Contact with children Other Safety issues Do you have any safety concerns around meeting the other party? Yes No Are any other agencies involved with your family? Yes No Court order / Injuctions Are any court orders / injunctions currently in place? Yes No Has the Court recommended that you use mediation? Yes No Please give dates of future court hearing: Appointments are during office hours. Please indicate which office you would prefer to attend by ticking one or more of the boxes below. Wembley Kilburn Please give details of any dates within the next month on which you are unable to attend due to other appointments (holidays, hospital appointments etc):
Appointment options: 1 Please set up an initial appointment for me alone 2 Please set up separate individual appointments for each of us 3 Please set up a joint appointment for the two of us If you have ticked box 2 or 3 above, we need both of you to sign and confirm you are willing to attend the initial meeting/s. Please sign Self Other party
Risk Assessment Please indicate which of the following have affected or are continuing to affect the family you are referring and what is the current level of risk: Safeguarding children Yes/No/Allegations High Low None Physical Abuse Sexual Abuse: Emotional Abuse: Neglect: Risk of Abduction: Other potential concerns Domestic abuse: Conflict between adults: Alcohol abuse: Drug/substance abuse: Mental health issues: Cultural issues: Religious issues: Immigration / asylum: Financial issues: Medical conditions adult/child: Physical impairments adult/child: Parenting skills Involvement of other family members in the contact:
Risk of violence towards staff: Risk of self harm: Other (please specify): Please return this form to address below: firstname.lastname@example.org Maypole Family Support Ltd 46 Harrow Road Wembley HA9 6PL Telephone: