Whilst the preferred method of submission is filling in the form below and pressing submit, if you wish to print the form and fill in by hand please click here to download a PDF. Once filled in, you can either fax of email the form back using the details provided.

Mediation information. This information will not be shared with your spouse

Your details

Your name:

Address:

Date of Cohabitation:

Telephone number:

Spouse/Partner Name:

Date of Marriage:

Email address:

DOB:

Date of Separation:

First name and age of each child including adult children:

Name

Age

+ Add Row

Significant Physical or Psychological health issues:

Other details

1. In 25 words, say what you hope to achieve in mediation

2. What would you say got your relationship to this point?

3. Would you choose to maintain your marriage/relationship if you had that choice?

4. How do you think your spouse might answer question 3?

5. On a scale of 1 is lowest and 10 is highest, how would you rate the level of conflict in your relationship now?

6. Would you say your conflict style is to avoid/accommodate/be assertive?

7. Would you say your spouse's conflict style is to avoid/accommodate/be assertive?

8. Are you intimidated by your partner? If yes, please give brief details:

9. Has a report ever been made to Police?

10. Have you seen a couples counsellor?

11. Have you seen a counsellor for your own support or therapy?

12. Are you aware of any of your own behaviour that upsets or makes your spouse/partner react strongly? If so, please briefly describe the behaviour.

13. Is there any specific behaviour of your spouse that upsets you or makes you react strongly? If so, please briefly describe the behaviour.

14. Who has been the main manager of money in your marriage/relationship?

15. Do you think your spouse has controlled the money?

16. Do you think your spouse will provide all requested financial information?

17. If you have children, do your children know about your separation?

18. If you have children, are you interested in receiving information about children and separation?

19. If you have children, do you have any concerns about your children arising from your separation?