The Mediation Centre
7/8 St.Mary's Grove, Stafford, ST16 2AT

Mediation phoneline :
01785 273133

e-mail us at : tmc@nowellmeller.co.uk

Public Funding (free Legal Aid) may be available¹

Search The Mediation Centre

Self Referral Form

Untitled Document

Your information

Name :		*
Date of birth :		*
Address :		*



Postcode		*
Home telephone number:
Work telephone number:
Mobile telephone number:

* indicates mandatory information

Partner's information

(Any contact information you may have is extremely useful)

Name :		*
Date of birth :
Address :		*



Postcode
Home telephone number:
Work telephone number:
Mobile telephone number:

* indicates mandatory information

Your solicitor's information

Name :
DX :
Telephone number :
Reference

1. Does your ex-partner have a solicitor?

Yes No I don't know
If yes please provide the solicitor's details here

2. Would you like a joint or separate assessment meeting?

Separate Joint

3. Has your ex-partner agreed to the referral?

Yes No

4. Which office would you like to meet at?

The Dudson Centre, Hope Street, Hanley Our Stafford Office

5. What are the likely issues?

Children Finance & Property Other

6. Does your partner know about the impending divorce/separation?

Yes No

7. Would you prefer us to write or telephone your ex-partner?

Write Telephone

8. Is there anything else you would like to tell us that you think might be helpful?

Nowell Meller Solicitors are Investors in People