Community Mediation Referral

Referral form for Professionals

Please complete the form below and upload your forms as requested:

Community Mediation Referral Form

Referrer Details:

Referral Agency

Town referral originated

Agency Contact

Contact Number

Email address

Address

Details of Parties Participating in Mediation: Party 1

First name

Current Address

Email address

Gender

Sexual orientation

Ethnicity

Individuals involved

Surname

Availability for meetings (please include working hours and days, standing commitments, availability in regards to children and school)

Contact number

Date of Birth required

Disability

Relation to other parties

Any potential risk to other parties involved (please specify)

Details of Parties Participating in Mediation: Party 2

First name

Current Address

Email address

Gender

Sexual orientation

Ethnicity

Individuals involved

Surname

Availability for meetings (please include working hours and days, standing commitments, availability in regards to children and school)

Contact number

Date of Birth required

Disability

Relation to other parties

Any potential risk to other parties involved (please specify)

Additional Information

Reason for referral (Please give a brief description of the dispute between the parties, as you understand it, and confirmation of any formal procedures that have so far been invoked, or any other attempts that have so far been made to resolve the dispute)

Please advise how long the dispute has been ongoing

Extent of police involvement (ie number of complaints by the parties involved and/or number of callouts by police)

Do any of the parties require any reason adjustments to be made due to any known disability of special educational needs or have a need for an interpreter of any kind?

Please tick to certify that permission has been sought for this referral to be made

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