Online PCIAM Booking Form | Family Mediation Trust

Full Name*

E-mail*

Phone Number*

Address*

Postcode*

Date of Birth*

Date of Birth

Have you had a PCIAM with the Trust before?

Please provide a brief overview of the situation you are looking for help with.

What issues would you like to address as part of the Parenting Coordination??

Improved communications
Understanding how communication impacts on the child
Managing own anxiety
Avoiding long term issues
Other

Income Information

The cost of the PCIAM and follow up information is based on a sliding scale as set out on our information page. This page has been set out together the required information for setting the correct fees. This information will be assessed by the PC in your first session and adjusted if required.

Following the completion of this form, the Team at the Trust will contact you regarding payments and appropriate fees.

Do you believe you are eligible for legal Aid

Yes I am on Universal Credit
Yes, I am on other benefits
Yes, I am on a VERY low income (less than £13,500 per year as a household)
I earn less than the Real Living Wage
My income between £18,855-£30,000 per year
My income between £30,000 -£50,000 per year
My income of £50,000+ per year

Legal Aid Evidence

If you believe you are eligible for Legal Aid support, please could you provide further information. This information will only be used in your assessment for Legal Aid.

Example Universal Credit evidence required can be found at:

(https://www.thefamilymediationtrust.org/key-information/legal-aid-support)

If you are on benefits please provide an up-to-date copy of your benefits statement. For example: this could be a screenshot from your UC account showing your last payments.

If you are on benefits , but not on Universal Credit, please provide an up to date copy of your most upto date bank staitment. this should include transactions up to today.

If you are employed, please provide attach a copy of your last payslip.

Second Party Details

Name*

Contact Address (if not know please state the address is not known)*

Email Field

Phone Number

Date of Birth

Children Involved

If you would like to address issues around children and child access, the Trust needs to understand who the children are and their ages.

Child 1: Please provide the birthdate, name and who this child predominantly lives with.

Child 2: Please provide the birthdate, name and who this child predominantly lives with.

Child 3: Please provide the birthdate, name and who this child predominantly lives with.

Child 4: Please provide the birthdate, name and who this child predominantly lives with.

Any additional children: Please provide the birthdates, names and who these children predominantly live with.

Please attach a copy of your court order or mediated agreement.

Please upload any other official documentation you feel may be of help to the PC.

Stage in Separation and Support

Do you have any legal procedures in place that may prevent mediation taking place? For example: restraining orders, bail conditions or non-molestation orders.

If you have a solicitor, please provide their name and address.

Consent

Please read the information below and confirm you agree to these terms and conditions.

Overview

This document outlines the process for using online and video (e.g. WhatsApp, Teams) for Parenting Coordination assessments and following meetings in parenting coordination (PC) cases.

Should a PC session or PCIAM be offered online or via video link, the following terms and conditions must be abided by.

Terms for Everyone

We agree that from this date any information shared in this meeting and in any mediation session will be confidential.

Confidential information cannot usually be used in legal proceedings. However, there are some exceptions:

• Financial information can be disclosed;

• The PC cannot keep confidential information where there is serious risk of harm to someone or where there is a suggestion of a financial crime, such as benefits fraud or tax evasion; and

• The Legal Aid Agency has the right to look at a file of anyone on legal aid. If one party is paying privately, that party can stop this.

We understand we are able to show confidential information to our professional advisors, but, subject to the exceptions, it cannot be used in legal proceedings.

To aid the development of new mediators, the Trust reserves the right for a trainee mediator to join the accredited mediator in the delivery of both PCIAMs and PC sessions.

The PC may not be asked to be a witness, or to provide information, in any legal proceedings. If the court requires the mediator to give evidence, then the parties will both be liable to pay the mediator's costs.

Terms for PC

• We will not audio or video record any mediation session, and nor will you. We will check with you that neither you, nor anyone on your behalf, will do so.

• We may terminate online video mediation if there is inadequate quality of connection or a breach of this agreement may have occurred.

• We may suspend the mediation if there is any remote interruption and will restart the online session once satisfied that any interruption has been resolved and that it remains appropriate to continue following such interruption.

Terms for Participants

• Only the people who have signed this agreement to PC online may be present in the same rooms used by the participants during any online video PC session. You will confirm that you are not able to be overheard from your location.

• You agree to do all you can to ensure that you are not interrupted during online video PC by anyone else such as children, relatives, pets, deliveries.

• You agree to turn off or put to silent any phones, tablets or computers, and disable any alerts announcements or notifications of texts, emails, tweets or other social media activity, and close all or any other open application.

• You agree to there being no live or deferred video or audio relay of the online mediation to third participants.

• You agree not to video or audio record any online session.

• You assign all intellectual property rights in the online video mediation sessions to the mediator.

• If you create any video or audio recording of the online PC, inadvertently or otherwise, you undertake to destroy any such recording as soon as you become aware of its existence.

Minimum recommended specifications for hardware and software (PC and participants):

• The latest version of the chosen webcam software for your device (most software will be supported to 2 major releases prior to the current one)

• A high-speed broadband connection (see below)

• High-quality or HD webcam

• Microphone and speakers (built-in or external headset with microphone)

• A desktop/laptop with a 2 GHz dual core processor or greater

• The latest version of Microsoft Internet Explorer, Mozilla Firefox, Google Chrome or Safari

• Minimum suggested broadband connection

• Minimum download speed 2Mbps/Minimum upload speed 1Mbps

Beginning and ending the session

• If using Skype, the participant will provide a Skype address that is unique to them.

• The Family Mediation Trust will initiate the session by Skype calling the account provided.

• At the beginning of the session the mediator will confirm that the above terms and conditions have been met, particularly that:

a) The participant will not create any electronic, video or audio record of the mediation.

b) The participant will not make or allow any live or deferred video or audio relay of the mediation to others.

c) Only the participants to the mediation and those who have signed the agreement to mediate will be present in the room used by each participant during any mediation session.

• If at any point during the session the above ‘Terms for Participants’ are breached, the mediator reserves the right to terminate the session. In such an instance the mediation may be postponed and rescheduled.

• At the end of the session the mediator will terminate the call.

• All other correspondence aside from the specified PC session will be made by telephone, email or letter.

Confidentiality and Data Protection

The Family Mediation Trust will handle your data and respect your privacy in accordance with data protection legislation and with the Service’s policies on Confidentiality, Data Protection and Privacy. For a copy of any of these documents please contact us on 01223 576 308 or PC@thefamilymediationtrust.org

Client agreement to PConline / via video link

I confirm that I have read and understood the above terms and conditions and that I would like to mediate online/via video link. I confirm that I will abide by the terms and conditions above.

I confirm that I have read the above consent and that I will abide by this agreement.

I confirm that the information provided on this form has been done so correctly and that I give permission to the Family Mediation Trust to use this information to deliver PC.

I confirm that by filling this form in I am liable to a fee for the PCIAM, unless the Trust believes I am eligible for Legal Aid support. If, based on information provided, the Trust believes I am eligible for Legal Aid then there will be a refundable deposit of £25 charged.

Name of person completing this form.*

Date form was completed.

Book a PCIAM