Voucher Client Consent Form

To claim a voucher contribution on your behalf, your mediator must legally obtain consent from both clients who have attended the Mediation Information Assessment Meeting (MIAM).

Please read the following consent form carefully to make sure that you understand and agree to the terms of the Family Mediation Voucher Scheme.

By completing this form, you will receive a digitally signed copy of the Family Mediation Voucher Scheme document via e-mail. Click here to view an unsigned copy of this document.

I have asked the mediator to apply for a contribution towards the cost of mediation from the Mediation Voucher Scheme. *

I have asked the mediator to apply for a contribution towards the cost of mediation from the Mediation Voucher Scheme.

I confirm that I have not already been approved for a voucher as part of the Scheme. *

I confirm that I have not already been approved for a voucher as part of the Scheme.

I understand my mediator will provide necessary information to the Ministry of Justice, including (but not limited to) my name, the bill for mediation services and some basic case information. *

I understand my mediator will provide necessary information to the Ministry of Justice, including (but not limited to) my name, the bill for mediation services and some basic case information.

I understand that the Ministry of Justice will hold my data in accordance with its Privacy Notice and client opt-in consents, which can be read *

I understand that the Ministry of Justice will hold my data in accordance with its Privacy Notice and client opt-in consents.

Email Address

Full Name *

Signature *

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Forms

Agreement to Mediate Form
Legal Aim for Mediation Form
Solicitor Referral
Family Mediation Voucher Form

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