Client Intake Form | P K Mediation

Client Intake & MIAM Information Form

CONFIDENTIAL

Thank you for choosing PK Mediation..

This confidential form helps us prepare for your Mediation Information and Assessment Meeting (MIAM). It should take approximately 5–10 minutes to complete. If you are unsure of an answer, you may leave it blank and discuss it with your mediator during your appointment.

Client Details

*Full Name*

*Email*

*Phone*

Birthday

Day

Month

Year

Address

Relationship Information

Relationship Status

Children

Are there any children involved in this mediation?

Mediation Issues

Please briefly describe the circumstances that have brought you to mediation and what you hope to achieve. If relevant, include any court proceedings, solicitor involvement, previous mediation, safeguarding concerns or other information.

Declaration

I confirm that the information I have provided is true to the best of my knowledge.

I have read and agree to the Privacy Policy.

I understand that PK Mediation is an impartial service and cannot provide legal advice.