Voucher Consent Form – Salam Mediation

Family Mediation Voucher Scheme

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.

Mediation Voucher Form

Mandatory confirmations:

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 partof 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 that the Ministry of Justice will hold my data in accordance with its Privacy Notice and client opt-in consents, which can be read at: Family Mediation Voucher Scheme

Optional permissions:

I consent to receive a diversity and inclusion questionnaire upon completion of my mediation to the above email address.

I consent that the MoJ may contact me to discuss the outcome of my mediation for research purposes at a future date using the above contact information.

First Name

Last Name

SM Case ID

Signature

Sign Here