Self-referral form

Use this referral form if you are a member of staff or student who wishes to refer themselves to the Mediation Service

Details of person referring direct

Contact details

Your name:

Are you a member of staff or student?:

Job title and faculty:

Contact details - email:

Contact details - phone number:

Details of other party to mediation

Contact details

Other party's name:

Other party contact Details - email:

Other party contact details - phone:

Type of working relationship

Please outline what your working relationship is with the other party, ie line manager, colleague, supervisor etc?

Details:

Details of case

Please provide a brief summary of the situation, including if the issue(s) are part of a grievance or any other formal process.

Details of Case:

Actions relating to case

Please provide brief details of any actions taken to date to resolve, investigate or otherwise manage the situation and their outcomes.

Actions relating to case:

Have you discussed mediation?

Have you discussed the possibility of mediation with the other party involved?

Related comments:

Other party contact?

Mediation Co-ordinator to contact other party?:

Venue requirements

Are there any specific venue requirements (ie disabled access) for a mediation meeting with both parties?

Details:

If you are human, do not fill this out

Thank you for completing this form. Once submitted you will be contacted by the Mediation Service shortly to discuss what happens next.

Mediation is confidential and all information relating to it, including the fact that you have approached the Mediaton Service will remain confidential and will not be disclosed to a third party.