Ministry of Justice Voucher Scheme - Ourkidsfirst Mediation

Family Mediation Voucher Scheme Client Consent Form

MOJ Voucher Consent Form

MOJ Mediation Voucher Scheme Questionnaire & Consent Form

To claim a voucher contribution on your behalf, your mediator must legally obtain consent from both clients who have attended the Mediation Information Assessment Meeting (MIAM). Please read the following consent form carefully to make sure that you understand and agree to the terms of the Family Mediation Voucher Scheme.

Your Full Name

Your Email

Your Phone/Mobile

Agreements

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, the bill for mediation services and some basic case information.

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 here

I have checked the voucher application form sent to me and have read the declarations on that form. I agree that this email can be taken as my electronic signature, and I understand that I am now applying for a Ministry of Justice voucher for family mediation

I consent to receive a diversity and inclusion questionnaire upon completion of my mediation to the above email address.

I consent that the MoJ may contact me to discuss the outcome of my mediation for research purposes at a future date using the above contact information.

If I am eligible for legal aid, and continue to apply for the MOJ voucher I understand that my support is limited to £500 per couple. I understand that I could get support beyond the £500 including help through the Help with Mediation Scheme but still want to continue.

Signature

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