Workplace Mediation Referral

Name of referring Officer

Position in Organisation

Name of Organisation including postcode

Phone number of referring officer (please give direct number -this will not be passed on to any third party)

Purchase Order number

Name of Party 1

Position in organisation

Additional information relevant to party 1 - please give brief details

Name of party 2

Position in organisation

Additional information relevant to party 2 - please give brief details

Other parties involved

Yes

Please give brief details

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 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 asessed by the referring organisation and is considered to be suitable for attendance by a DFA Mediator