Family Mediation

Mediation Voucher Scheme Consent Form

Your email:

Your first name

Your surname

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 AND AGREE

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

I UNDERSTAND AND ACCEPT

the Family Mediation Council will hold my data in accordance with its Privacy Notice for the Mediation Voucher Scheme which can be read at https://www.familymediationcouncil.org.uk/privacy-notice-mediation-voucher-scheme/

INSERT YOUR NAME to use as your electronic signature