Couples Mediation Referral Form

Referring to the Couples Mediation Service

Thank you for your request to refer to the above service. Before completing the Mediation referral form, please keep in mind that we offer:

v  Free mediation to couples, living together or apart

v  Mediation in order to reduce conflict and help to re-build relationships. This works best when used to prevent a situation getting to crisis point

v  Mediation involving the primary carers within the family, usually parents

v  Mediation where both people feel that there are difficulties in the relationship and for both to want to make change for improvement

v  A short term process; 6-8 sessions are usually offered. These sessions include helping couples to gain skills in communication so they can start to reduce the conflict themselves

v  An information session (45 minutes- 1 hour) which is the opportunity to individually meet with a mediator, find out about mediation and decide if mediation is the right service for you. The couple and the mediator will then decide what the next step will be

v  This process requires couples to take time out of their normal day to attend appointments, wherever possible

v  Mediation is confidential

Mediators do: / Mediators do not:
·  Listen to each party / ·  Give advice or tell anyone what to do
·  Help couples to gain new skills in communicating and managing conflict / ·  Take sides or represent one person
·  Help couples to find the right solutions for them / ·  Make judgments about families
·  Help couples to agree solutions for the future / ·  Go to family homes
·  Mediate in a neutral venue such as a community centre or a school

Sometimes, mediation is not the right service for all couples. If this is the case we will help you to think about what support might be better the family.

We would appreciate it if you could include as much information as possible on the referral form. This is to give us an opportunity to know more about the family and their needs, and to ensure that we are an appropriate service for the family. The form can be completed by the couple themselves, or by a professional who is working with the family.

If you are in any doubt about whether this is an appropriate referral or to talk through the form please contact the Mediation service on 03333 202 384

Considering the above information if you feel our service is appropriate to meet the family’s needs please complete the following form. All sections need to be completed.

DATE
REFERRERS’ DETAILS
Name of Referrer / Email
Job role / Contact number
Organisation / Mobile No:

To help us to track the family’s outcomes, please include the case number of the family members for the case management system you are using. If you are using a system not listed here, please add the system name below.

ECAF / EHM / IES /Indigo Number: Parent 1
ECAF / EHM / IES /Indigo Number: Parent 2
ECAF / EHM / IES /Indigo Number: Child 1
ECAF / EHM / IES /Indigo Number: Chid 2
ECAF / EHM / IES /Indigo Number: Child 3
ECAF / EHM / IES /Indigo Number: Child 4
ECAF / EHM / IES /Indigo Number: Child 5
PARTIES WANTING MEDIATION
Party 1 (Please indicate position in family e.g. Parent / Carer / Party 2 (Please indicate position in family e.g. Parent / Carer)
Name / Name
DOB / Age / DOB / Age
Gender / Gender
Ethnicity / Ethnicity
Current address / Current address
Post Code / Post Code
Home Phone / Home Phone
Mobile Phone / Mobile
Email / Email
Direct agreement to referral received (Please tick) / Direct agreement to referral received (please tick)
We would be grateful if you could complete the following information to enable us to evaluate the appropriateness of our service:
How would you describe the mental health and emotional wellbeing of the couple, advising us of any specific concerns or professional diagnosis of mental ill-health:
Please tell us about any concerning drug or alcohol use of either party:
Please advise us of any offending history for either party within the past two years, including any pending case:
To what extent does the conflict between the couple escalate into physical, mental, emotional or other abusive behaviour (e.g. throwing/breaking things in the home):
Are there any previous or current restraining orders / restrictions / risks / regarding any family members or children? If unknown have the family worked with other agencies e.g. CAFCAS?
Has either been diagnosed with a special need or disability? If so, please describe what this is:
Please let us know of any other information you feel is relevant:
Please use an additional sheet of paper if necessary.
ADDITIONAL INFORMATION
Please describe what has happened in the family that has resulted in this referral to mediation:
How would the couple / family like mediation to help?
Where did you hear about the service?
AGENCY DETAILS Please list any other agencies or professionals that you are working with:
Name / Name
Agency / Agency
Contact Details / Contact Details
I agree for hyh to contact the above agencies to further support the progress of my referral / Yes / No
Thank you for completing this form. Please return the form as follows:
By email using HertsFX:
If you do not have a HertsFX account, please email for assistance – do not send personal data using an unencrypted email system