Make A Referral Form

If you wish to make a referral to Hethertons Mediation, please fill in the form below. Once received, we will contact you directly to arrange a mutually convenient appointment for you to attend for a Mediation Information Assessment Meeting (MIAM).

If you require any further information, please feel free to contact us by email at enquiries@hethertonsmediation.co.uk, by phone on 01904 528200, or by fax on 01904 791506.

Client Referral Form

* required fields

About You

Your Details








Solicitor Details (if applicable)








About the other person

Other Person's Details








Solicitor Details (if applicable)








Details of any children

Child to both of you YesNo
Child to both of you YesNo
Child to both of you YesNo
Child to both of you YesNo
Child to both of you YesNo
Child to both of you YesNo

Mediation Details

SeparationMatrimonial FinancesCo-habitation FinancesChildren- living arrangementsChildren- contactParental ResponsibilityOther

If other please specify


YesNo


YesNo