Mediation Voucher Scheme Questionnaire & Consent Form

Please carefully read the document Mediation_Voucher_Scheme_Questionnaire_and_Consent_Form.pdf, which you can view by clicking the button below:

You can either download this document, print, sign and post back to us or you are now able to complete and sign using your Mouse/Trackpad on your PC/laptop or your finger on mobile devices.

If you would like to complete the form online, please complete the form fields, these will populate into the correct areas of the agreement and will be sent to us electronically. You will also receive an email with a copy for your reference.

Mediation Voucher Scheme Questionnaire & Consent Form

    First Name



    Mediation service that applied for the voucher

    If there was no mediation voucher, would you have pursued mediation?

    What is your ethnic group?

    Please describe your ethnic background

    How would you describe your sexual orientation?

    What was your sex registered at birth?

    Is the gender you identify with the same as your sex registered at birth?

    Do you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more?

    What is your religion or belief?

    What is your legal marital or registered civil partnership status?

    Are you currently pregnant?


    Signature - use your mouse or finger to sign in the area below

    Do you have any questions?

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