Referral Form


If you would like to make an appointment, please complete and submit our Referral Form (or ask your solicitor to do this for you)

Once received, we will contact you to set up an appointment
*All asterisked boxes must be completed

The fee for your MIAM/assessment meeting is £95. This is payable when booking your appointment. We accept payment by credit/debit card. This fee is refundable if you prove eligible for legal aid (subject to our cancellation policy) when you attend your appointment.

If you wish to pay by cheque you will have the opportunity to download a completed form to send along with your payment to: WYFMS, 33 Manor Row, Bradford, BD1 4PS.

Legal aid for family mediation
If you are currently receiving any of the following benefits: Income support / Income-based JSA / Income-based ESA / Guarantee Credit / Universal Credit, we may be able to offer your MIAM appointment at a reduced fee - please contact us on 01274 732768.
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Thank you

We've received your referral request and a member of our team will contact you in due course to arrange your appointment


You can now use the below link to download a completed copy of your form
Your details
Other person's details
Title (Mr/Mrs etc)*
First name(s)*
Surname*
Address*
Date of birth (DD/MM/YY)
Relationship to other person*
Contact Telephone No.*
Email Address
Occupation
Title (Mr/Mrs etc)*
First name(s)*
Surname*
Address
Date of birth (DD/MM/YY)
Relationship to other person
Contact Telephone No.
Email Address
Occupation
What do you want to discuss / resolve in mediation?*
Child related matters (contact, residence, shared care, maintenance)
Property matters & financial matters (savings, pensions, family home, assets, debts)
All issues (children plus property and finance)
Other matters (please specify)
Court applications*
Has an application been made to the court about these issues?

Details of children
Full name
Age
Boy/Girl
Date of birth
Living with
Relationship to you
Your solicitor
Other person's solicitor
Solicitor name
Telephone No.
Company
Email
Address
Solicitor name
Telephone No.
Company
Email
Address
Safety in mediation*
Is there a history of domestic abuse in your relationship?
Are there any child protection issues?
Appointments
Please advise if you would like to attend your MIAM/assessment meeting in:
Bradford
Leeds
Please advise of any special arrangements required (eg wheelchair access, interpreter/language, etc.):
Finally, please tell us who made this referral*
This referral was made by .
Submit Referral Form
You will be given an opportunity to download your completed form as a PDF on the next page,
if you wish to print and post your application along with a cheque or postal order.