Your details:

Full Name:

Address 1:

Address 2:

County:

Postcode:

Tel:

Email:

Brief Description of Claim:

Are you? (please tick)

Claimant

Defendant

Your Solicitor (or other advisor):

Name:

Firm:

Address 1:

Address 2:

County:

Postcode:

DX Address:

Tel:

Email:

Other Side's details:

Full Name:

Address 1:

Address 2:

County:

Postcode:

Tel:

Email:

Other side's Solicitor (or other advisor):

Name:

Firm:

Address 1:

Address 2:

County:

Postcode:

DX Address:

Tel:

Email:

Please confirm that both sides have agreed to follow the mediation process

Yes

No

In which location would you ideally like the mediation to take place?

No preferred location (please tick)

Within what timescale are you seeking to conclude the mediation?

Are there any issues we should consider when recommending a mediator to facilitate your case?