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

Tailor your MIAM form

Please help us tailor the mediation process to your needs by answering the following questions. This ensures our sessions are focused and relevant to your specific circumstances.

Why are you seeking mediation?

Separation / divorce

Financial settlements

Child arrangements

Child maintenance

Other (please specify)

Other

Your current relationship status?

Married (legally registered)

In a civil partnership

Religiously married (not legally registered)

Cohabiting / living together

Divorced

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

Relationship

This optional section helps us understand the nature of your relationship. Please share important dates and any other relevant details.

Your current relationship status:

Date of marriage

Date of civil partnership

Date of cohabiting / living together

Religiously married

Date of separation

Have you applied for a divorce petition?

Yes

Date of divorce petition

Have you received the Final Order?

Yes

Date of Final Order

Have you religiously divorced?

Yes

Date of religious divorce

Have you divorced?

Yes

Date of divorce

Have you received the Conditional Order?

Yes

Date of Conditional Order

Please share a brief summary of the main issues or concerns that brought you to mediation.

Do you have any safety concerns?

Yes, please state below

Please state your safety concerns.

Eligibility check

Has the other party had any history of drug abuse (class A/B drugs)?

Has the other party had any history of alcohol misuse or binge drinking?

Has the other party been involved in any domestic violence or intimidation?

Does the other party have any mental health needs?

Has the other party ever self-harmed?

Are there any ongoing court proceedings involving the other party?

Are there any current or past court orders involving the other party?

Any other relevant information?

Yes, please state below

Other relevant information.

Are you living with a new partner?

Yes

Do you intend to live with a new partner within the next six months?

Yes

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

On a scale from 1 to 10, how would you describe your current level of amicability with other party?

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.

Name of the child with special needs and their details

With whom are the children currently living with?

Mother

Father

Both parents

Other, please specify

Please specify with whom are the children currently living with.

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

Do you own property?

Yes, provide more information

Please provide property details below (value, equity, mortgage, payments, etc.)

Do you own investment property or land?

Yes, provide more information

Please provide details below for each investment property (value, equity, mortgage, payments, etc.)

Property

Do you own property or land abroad?

Yes, provide more information

Please provide details below for each property or land abroad (location, value, equity, mortgage, payments, etc.)

Property

Do you own a business?

Yes, provide more information

Please provide business details below (value, type of business, etc.):

Do you have a pension plan?

Yes, provide more information

Please provide pension details below (type, approximate value, etc.)

Do you have savings or investments?

Yes, provide more information

Please provide savings details below (type, approximate value, etc.)

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

Please state what you are concerned about.

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

Please describe the nature of your disability.

Do you identify with a neurodiverse condition?

Yes, please state below

Prefer not say

Please describe the nature of your neurodiverse condition.

What is your ethnic origin?

Please specify 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

First preferred time

Second preferred date

Second preferred time

Payment information:

Account Holder: Salam Mediation
Bank Name: Monzo Bank
Sort Code: 04-00-03
Account Number: 44970896
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.