MIAM Form – Salam Mediation

Your MIAM form

Remember to save your form. You can return to it later or email the link to yourself. Once completed, please ensure to submit the form.

MIAM Form

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General information

Kindly fill out the relevant information below. Our preferred methods of communication are phone, email, and WhatsApp.

First Name

Last Name

Date of birth

Mobile / WhatsApp

Gender

Consent for CC in email communications with other party.

Yes, I agree to be CC'd where relevant.

No, I prefer not to be CC'd

Occupation

Address

City

County

Postcode

Other party’s details

Please provide complete details for the other party. If full details are not available, ensure at least one form of contact information is provided.

First Name

Last Name

Date of birth

Phone/Mobile

Gender

Occupation

Address

City

County

Postcode

Children’s details

Please provide complete details for each child involved. If full details are not available, ensure at least basic information such as name and age is provided.

Do you have any children?

Yes, and have more than one child, please click add.

Children's detail

Full name	Date of birth	Gender

Do any of the children have special needs, disabilities, or learning difficulties?

Yes, please specify which child and provide details.

With whom are the children currently living with?

Mother

Father

Both parents

Other, please specify

Are the children aware of the situation between you and your husband / wife / partner?

Yes

Not sure

Financial information

Please provide some basic information about your financial situation. This will help us understand the context of your mediation without going into detailed financial discussions at this stage.

Are there any financial matters you would like to address in mediation?

Yes

Mediation

I understood mediation as being voluntary, confidential and neutral.

Yes

I have been involved in mediation before.

Yes

Mediation is usually conducted with both of you present together. Does this create any concerns for you?

Yes, please state below

Equal opportunities

Completion of the ethnic origin and disability field is voluntary. However where a client is willing to provide this information it will greatly assist us in monitoring and researching access to LAA funding services in line with their commitment to promote equal opportunities set out in the Equality Scheme. This information will be treated in the strictest confidence and will be used for physical monitoring and research.

Do you have a disability?

Yes, please state below

Prefer not say

What is your ethnic origin?

Booking your MIAM session

Thank you for completing the form. You're just a few steps away from scheduling your Mediation Information and Assessment Meeting (MIAM).

To confirm your session, please provide your available dates below. Once we receive your payment, we will do our best to find a suitable date that accommodates your schedule and confirm your session promptly.

Suggest your availability

Please suggest your available dates for the MIAM session. Providing more than one option will help ensure that we can accommodate your schedule efficiently.

First preferred date

Second preferred date

First preferred time

Second preferred time

Payment information:

Account Holder: Salam Mediation
Bank Name: Mettle Bank
Sort Code: 04-03-33
Account Number: 28761140
Reference: Use your full name

Once we receive your payment, we will confirm your session and inform you. We look forward to assisting you further and thank you for choosing Salam Mediation.

Confirmation before submission

By submitting this form, I confirm that I have read and understood the Agreement to Mediate provided link. I affirm that the details I have provided are accurate to the best of my knowledge. I agree to abide by the terms outlined in the Agreement to Mediate.