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The University of Southampton

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

    Details of other party to mediation

    Contact details

    Type of working relationship

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

    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.

    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.

    Have you discussed mediation?

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

    Other party contact?
    Venue requirements

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

    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.


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