£500 Mediation Voucher Application | Becky Taylor Mediation

1. Your Details

Your Full Name *

Your Email *

Your Phone *

2. Eligibility

Have you attended a MIAM with Becky Taylor Mediation? *

MIAM Date (if attended)

Does your mediation involve arrangements for children? * Yes No

Have you received a family mediation voucher before? * No Yes The voucher (currently up to £500) is available for eligible mediations involving children, once per person. We apply on your behalf and will discuss eligibility at your MIAM.

3. Voucher Scheme Consent

To claim a voucher contribution on your behalf, your mediator must legally obtain consent from both clients who have attended a Mediation Information and Assessment Meeting (MIAM). Please read the following consent statements carefully and tick each one to confirm you understand.

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 part of the Scheme.

I understand my mediator will provide necessary information to the Ministry of Justice, including (but not limited to) my name and the bill for mediation.

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: familymediationvoucherscheme.co.uk/claim/en-GB/privacy-policy

This consent can be given online below, or by signing and scanning/photographing the paper consent form and emailing it to your mediator.

Sign on screen (draw with finger/mouse)

Or type your name — either method is accepted; you do not need to do both.

Type your full name (this is your signature)

Date

I consent to Becky Taylor Mediation storing and processing this information to apply for the voucher, as described in the Privacy Policy. *

Leave this field empty

The other party must also give consent — they can use this same form: Agreement to Mediate

£500 Voucher Application

1. Your Details

2. Eligibility

3. Voucher Scheme Consent

Sign on screen (draw with finger/mouse)