Landlord & Tenant Mediation Referral

Name of Officer making referral

Position of Officer in organisation

Date

Organisation

Organisation address

Postcode

Phone (Please give the referring officers direct line - this will not be passed on to any third party)

Purchase Order number

Name of Tenant(s)

Address of Tenant(s)

Type of tenure

Contact phone number of tenant(s)

Other parties involved

Yes

Please give brief details

Brief details of the case with any relevant information including, family makeup, language difficulties, disabled access requirements etc.

I confirm that the applicants have agreed to allow disclosure of the details to a third party

The applicants have been made aware of the purpose and principles behind mediation

The case has been risk assessed by the referring organisation and is considered suitable for attendance by a DFA Mediator