Kee Mediation | Client Referral form

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Client Referral form

Kee Mediation – Referral Form

Kee Mediation Referral Form

Please complete the details below to proceed with your mediation booking.

1. Case Details

Case Type *

Funding Path *

2. Your Details (Applicant)

Full Name *

Email Address *

Phone Number *

Date of Birth *

Full Address *

Legal Aid Assessment Requirements

Because you selected Legal Aid, we require the following details to verify your eligibility prior to your MIAM.

National Insurance Number *

Benefit Received *

Upload Evidence (e.g. UC Portal Screenshot showing Gov.uk banner) *

Max file size: 5MB. Accepted formats: JPG, PNG, PDF.

Property & Assets

Do you own a property? *

Do you have savings/investments >£8k? *

Estimated Property Value (£)

Mortgage Outstanding (£)

Ownership Split (e.g., 50/50)

Do you live with a partner?

Is this property the Subject Matter of Dispute (SMOD)?

Select ‘Yes’ if this property is actively being disputed in the mediation.

3. The Other Party’s Details (Respondent)

Please provide as much contact information as possible so we can invite them to mediate.

Full Name *

Email Address

Phone Number

Address (if known)

4. Final Details

How did you hear about us? *

Ethnic Origin *

Do you consider yourself disabled? *

Consent to Contact: I confirm that I am happy for Kee Mediation to contact the other party using the details provided above to invite them to participate in mediation.

Note: As a Private client, you will be redirected to our secure Stripe portal to process the MIAM booking fee upon submission. Your appointment is not secure until payment is cleared.

How to complete this form

Select the options as they apply to you as much as you can.

If you are applying for Legal Aid, you need to add a screenshot of your most recent Universal Credit payment.