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What do you need help with?
Please select at least one of the following:
Please select at least one of the following:
Separation dissolution or divorce
Child arrangements
Financial settlements
Child maintenance payments
Other (please specify)
Other
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General information
Name
First
Last
Email
Email
Confirm Email
Mobile
Address
Address Line 1
City
State / Province / Region
Postal Code
Date of birth
Occupation
whom you summary
Previous
Next
Relationship
This optional section helps us understand your relationship's nature and length. You can share key dates, such as marriage, separation, or divorce proceedings, and any other relevant details.
Date of marriage / civil partnership
Date of marriage / civil partnership
Conditional order
Conditional order (if applicable)
Date of separation / petition for divorce
Date of separation / petition for divorce
Final order
Final order (if applicable)
Please share a brief summary of the main issues or concerns that brought you to mediation.
Do you have any safety concerns?
Yes
No
if yes, please state below
Do you have any safety concerns? yes
Eligibility Check (please confirm the following about the other party, if relevant):
Has the other party had any history of drug abuse (class A/B drugs)?
Has the other party had any history of alcohol misuse or binge drinking?
Has the other party been involved in any domestic violence or intimidation?
Does the other party have any mental health needs?
Has the other party ever self-harmed?
Are there any ongoing court proceedings involving the other party?
Are there any current or past court orders involving the other party?
Any other relevant information?
Yes
No
if yes, please state below
Any other relevant information? yes
Are you living with a new partner?
Yes
No
Do you intend to live with a new partner within the next six months?
Yes
No
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The other party’s details
Name
First
Last
Email
Email
Confirm Email
Mobile
Address
Address Line 1
City
State / Province / Region
Postal Code
Date of birth
Occupation
Next
Children’s details
Do you have any children?
Yes
No
If yes, and have more than one child, please click add.
Child's name
Gender
Please select
Boy
Girl
Date of birth
Age
Add another child
Remove child
Do any of the children have special needs, disabilities, or learning difficulties?
Yes
No
If yes, please specify which child and provide details.
Do any of the children have special needs, disabilities, or learning difficulties? Yes
With whom are the children currently living with?
With whom are the children currently living?
Yes
No
Not sure
Next
Equal opportunities (voluntary)
Equal opportunities monitoring and gender disability and ethnic origin.
Completion of the ethnic origin and disability section is voluntary. Providing this information, if you choose to do so, will help us monitor and improve access to our services in line with our commitment to promoting equal opportunities as part of our Equality Policy. This information will be treated with the utmost confidentiality and used solely for monitoring and research purposes.
Do you have a disability?
Yes
No
Prefer not say
If yes, please specify the nature of your disability
Optional
How would you describe your ethnic origin?
White British
White other
White Irish
Chinese
Asian or Asian British Indian
Asian or Asian British Pakistani
Asian or Asian British Bangladeshi
Asian or Asian British Other
Mixed White & Asian
Black or Black British African
Black or Black British Caribbean
Black or Black British Other
Mixed White & Black Caribbean
Mixed White & Black African
Mixed other
Other
Prefer not say
Submit
