Neighbourhood Mediation Referral

Name of Officer making referral

Position of Officer in organisation

Date

Organisation

Organisation Address

Organisation Postcode

Officers direct contact phone number (This will not be passed on to any 3rd party)

Purchase Order number

Name of Party 1

Address of Party 1

Contact phone number - Party 1

Name of Party 2

Address of Party 2

Contact phone number of Party 2

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

Do the parties wish for shuttle mediation? (This is where parties do not wish to meet face to face)

Yes

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.