Client Form for a MIAM, Family Mediation, Divorce Mediation or Parenting Mediation By completing this form we will spend less time during your initial appointment asking you questions and more time helping you consider your options. Completed forms are kept confidentially by Start Mediation Ltd and any information you provide on this form will not be shared with anyone else without your permission (and we will discuss any exception to this with you). By submitting your completed form, you consent to your data being collected and stored. Step 1 of 5 - Introduction 0% This form can be saved after the completion of any page by clicking on 'Next'. This will save it so that you can come back and complete it later, but you must be using the same device and browser. Also, you must avoid clearing your browser's cache. After submitting it, a copy will automatically be sent to the email address you provide for yourself. Your detailsName* First Last Primary phone number*Mobile number, if different.Email address*NOTE: this is the address which a copy of this form will automatically be sent to. Postal address* Street Address Address Line 2 Town or City Post Code or ZIP Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Date of birth* OccupationDo you think you might qualify for legal aid? NOTE Legal Aid will not allow for a MIAM (Mediation Information and Assessment Meeting) over the internet.*YesNoWhat is your total monthly net (after tax) income from the following: employment, self-employment; tax credits, child benefit, other state benefits, spousal maintenance; child support and any other source.*What is the approximate value of any property you own, after deducting the value of any mortgage?*What is the approximate value of your savings, jewellery, investments or valuable possessions?*Do you think the person who you share a problem or dispute with might qualify for legal aid?*YesNoDo you live with a spouse or partner?*YesNoPlease provide their total monthly net (after tax) income from the following: employment, self-employment; tax credits, child benefit, other state benefits, spousal maintenance; child support and any other source.*Before mediation starts, you will need a MIAM (Mediation Information and Assessment Meeting) or suitability meeting with a mediator. These can be held at our consulting rooms in Ipswich or from your home or workplace over the internet. You can attend on your own or together with the other person you have a problem or dispute with. Which type of meeting would you prefer? We recommend you only choose a "Together" option if you have spoken to the other person about it and they have already agreed to it. Please note legal aid does NOT allow MIAMs or mediation to take place over the phone or internet.*On my own with you in Ipswich.Together with the other person with you in IpswichOn my own with you over the internetWe can use Skype, FaceTime and WhatsApp to meet with you online. If you don't have one of these we can provide an alternative which will not require you to open a user account. Which would you prefer?*SkypeFaceTimeWhatsAppAn alternativeWhat is your Skype name?*What phone number is registered to your FaceTime profile?*What phone number is registered to your WhatsApp account?*Do you have any disabilities or health concerns you would like us to know about?YesNoPlease provide details: Details about the person you share a problem with or who you are in dispute withTheir name* First Last Are they aware that you want to meet with a mediator?*YesNoTheir date of birth (or age)*Their occupationYour relationship to them*Are married and live togetherAre married and have separatedAre married and are divorcingWere married and have divorcedAre in a civil partnership and live togetherAre in a civil partnership and have separatedAre in a civil partnership and are dissolving itWere in a civil partnership which has been dissolvedAre living togetherWere living togetherHave never lived togetherDid you live together before you got married or entered civil partnership?*YesNoWhen did you start living together?*When did you marry or enter into a civil partnership?*When did you separate?*Have you discussed separation, dissolution or divorce?*YesNoAre you interested in reconciliation?*YesNoWho made the decision to end the relationship?*MeOther personBoth of us togetherWho started the divorce or dissolution proceedings?*MeOther personWhen were court proceedings started?*When was the divorce or dissolution finalised?*Their postal address* Street Address Address Line 2 Town or City Post Code or ZIP Country AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Their email address Their main telephone numberHow would you describe their health?Are there of any religious, ethnic or cultural issues which could be relevant?YesNoPlease provide details Children under 18 or still in full-time education or still dependant for other reasons, and other dependantsDo you have a child under 18 or still in full-time education or still dependant for other reasons?*YesNoChild 1Name First Last Date of birth Do you have Parental Responsibility?YesNoDon't knowLiving withMeOther parentAny special needs?How would you describe their health?Is the other person a parent to this child?YesNoDo you have a second child?YesNoChild 2Name First Last Date of birth Living withMeOther parentAny special needs?Do you have Parental Responsibility?YesNoDon't knowHow would you describe their health?Is the other person a parent to this child?YesNoDo you have a third child?YesNoChild 3Name First Last Date of birth Living withMeOther parentDo you have Parental Responsibility?YesNoDon't knowAny special needs?How would you describe their health?Is the other person a parent to this child?YesNoDo you have a fourth child?YesNoChild 4Name First Last Date of birth Living withMeOther parentDo you have Parental Responsibility?YesNoDon't knowHow would you describe their health?Any special needs?Is the other person a parent to this child?YesNoDo you have a fifth child?YesNoChild 5Name First Last Date of birth Living withMeOther parentDo you have Parental Responsibility?YesNoDon't knowHow would you describe their health?Any special needs?Is the other person a parent to this child?YesNoDo you have a dependent who is not a child, or do you live with someone who you have not already mentioned?NoYesPlease provide detailsWhat do you and other parent do best as parents?What are your hopes for your relationship with the other person?Do you have any concerns about any child's emotional or physical safety with you or the other person?NoYesPlease provide detailsHas a child ever witnessed any incident of physical, verbal or emotional abuse?NoYesPlease provide details.What effect do you think your relationship with the other person has on your child or children?*A great dealSomeCouldn't sayA littleNone at all Do any of the following apply to you or your relationship with the other person?Have there been any incidents of drug or alcohol abuse?* Yes No Please provide the details:Do either you or the other person suffer from mental or physical health problems?* Yes No Please provide the details:Have you or the other person any reason to be fearful of each other, ever threatened to hurt each other, hit or used any other type of physical force towards each other, or emotionally, culturally or sexually abused each other? Have you or the other person called the police, requested a protection order or sought help as a result of abuse by the other person?* Yes No Please provide the details:The problem or dispute you want to discussPlease describe the problem that exists between you and the other person.*What are the obstacles, if any, to you and the other person reaching your own agreement?*Judges expect parents or spouses to attempt to solve their problems through mediation before making a court application. Are you willing to mediate?*YesNoPlease give your reasons.Judges expect potential respondents to also meet with a mediator before any application to court is made. Do you believe the other person might be willing to mediate?*YesNoPlease give your reasons.Please use this space to tell us about anything else relevant to this problem or dispute.Professional representationDo you have a lawyer?YesNoLawyer's name First Last Name of law firmLawyer's email address Lawyer's phone numberWhere did you first hear about us?*You contacted me.Searched Google and saw your name.Searched Google and saw your ad.Searched Bing and saw your name.Searched Bing and saw your ad.Recommended by a lawyer.Recommended by a friend.Found your name on the Family Mediation Council website.Found your name on the Family Mediators Association website.Date*
