Mediation Voucher Scheme Questionnaire & Consent Form

First Name

Surname

Email

Mediation service that applied for the voucher
Allison Family Mediation Services

If there was no mediation voucher, would you have pursued mediation?
Rather not sayYesNo

What is your ethnic group?
Rather not sayWhite - English/Welsh/Scottish/Northern Irish/BritishWhite - IrishWhite - Gypsy or Irish TravellerMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianAsian/Asian British - IndianAsian/Asian British - PakistaniAsian/Asian British - BangladeshiAsian/Asian British - ChineseBlack - CaribbeanBlack - AfricanBlack - BritishArabOther

Please describe your ethnic background

How would you describe your sexual orientation?
Rather not sayHeterosexual/StraightGay/LesbianBisexualOther

What was your sex registered at birth?
Rather not sayMaleFemale

Is the gender you identify with the same as your sex registered at birth?
Rather not sayYesNo - FemaleNo - MaleNo - Other or non-binary

Do you have any physical or mental health conditions or illnesses lasting or expected to last for 12 months or more?
Rather not sayYesNo

What is your religion or belief?
Rather not sayNo religionChristian (including Church or England, Catholic, Protestant and all other Christian denominations)BuddhistHinduJewishMuslimSikhAny other religion, please describe

What is your legal marital or registered civil partnership status?
Rather not sayNever married and never registered in a civil partnershipMarriedIn a registered civil partnershipSeparated, but still legally marriedSeparated, but still legally in a civil partnershipFormerly in a civil partnership, which is now legally dissolvedSurviving partner from a civil partnershipWidowed

Are you currently pregnant?
Rather not sayYesNo

I consent to my mediator applying for a contribution towards the cost of mediation from the Mediation Voucher Scheme which was launched on 26 March 2021

I confirm that I have not made another application for a mediation voucher under the Scheme

I understand that my mediator will submit case information to the Family Mediation Council which will be used for research purposes

I understand that the Family Mediation Council will hold my data in accordance with its Privacy Notice for the Mediation Voucher Scheme

Date

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