Agency Referrals Referral Form: Agency referrals for conflict Please complete the form below or download the referral form to print and complete. Tick here if this is a self referral: Self Referral If you are a housing provider and are not in a contract with us has funded been approved for us to take on this case? YesNo Purchase Order number About You (Referrer) Your Name Your Agency Your Team Your Reference No for case Direct Tel No Your Email* Is this referral part of a: Community RemedyInjunctionABCOther Details of parties (Party A) Title (Mr/ Mrs/ Ms/ Other) Name Address Postcode Housing Status Mobile Telephone (Landline) E-mail Preferred contact for party A? Please check parties have given explicit consent for us to contact them using all of the details provided Any additional people in property that are involved in this conflict? (please list all including names, ages and ethnic origin) Any additional issues that we need to be aware of, that may affect partes, ie mental health, addiction issues, vulnerability, any known risks, animals? Please include details: Are there any supporters involved? yesno Gender MaleFemaleOtherPrefer not to say Is Gender different to that assigned at birth YesNo Age <1313-1718-2425-4950-6465-7475+Prefer not to say Ethnicity First Language Interpreter/translator required? yesno Religion (If known) Sexual Orientation (if known) Any known disabilities Details of parties (Party B) Title (Mr/ Mrs/ Ms/ Other) Name Address Postcode Housing Status Mobile Telephone (Landline) E-mail Preferred contact for party B? Please check parties have given explicit consent for us to contact them using all of the details provided Any additional people in property that are involved in this conflict? (please list all including names, ages and ethnic origin) Any additional issues that we need to be aware of, that may affect partes, ie mental health, addiction issues, vulnerability, any known risks, animals? Please include details: Are there any supporters involved? yesno Gender MaleFemaleOtherPrefer not to say Is Gender different to that assigned at birth YesNo Age <1313-1718-2425-4950-6465-7475+Prefer not to say Ethnicity First Language Interpreter/translator required? yesno Religion (If known) Sexual Orientation (if known) Any known disabilities Details of parties (Party C) Title (Mr/ Mrs/ Ms/ Other) Name Address Postcode Housing Status Mobile Telephone (Landline) E-mail Preferred contact for party C? Please check parties have given explicit consent for us to contact them using all of the details provided Any additional people in property that are involved in this conflict? (please list all including names, ages and ethnic origin) Any additional issues that we need to be aware of, that may affect partes, ie mental health, addiction issues, vulnerability, any known risks, animals? Please include details: Are there any supporters involved? yesno Gender MaleFemaleOtherPrefer not to say Is Gender different to that assigned at birth YesNo Age <1313-1718-2425-4950-6465-7475+Prefer not to say Ethnicity First Language Interpreter/translator required? yesno Religion (If known) Sexual Orientation (if known) Any known disabilities What is it about? Access/Boundary dispute (including hedges)AnimalsAbusive, Aggressive, Antagonistic BehaviourBreach of privacy (eg: CCTV, security lights, photos/videosCommunal AreasChildren's behaviourGarden EncroachmentGossipingHate/DiscriminationBullying/Intimidation/HarassmentLifestyle DifferencesNoise (including boiler, utility and white goods)Property DamageProperty Neglect (eg: Untidy, Rubbish, Overgrown)Property/Building RenovationsRelationship BreakdownSmellsSocial Media HarassmentCars, Parking, Vehicle RepairsVisitors, Comings and GoingsOther-please give details below How long has the dispute been going on? Has anything else been put in place, ie diaries, Noise monitoring etc Any police involvement (if possible please give Name of attending officers/dates/outcomes Any other agencies involved (eg SARI, Noise Pollution, Environmental Services etc) ……… (please give names/contact details if possible) Any previous mediation? (If yes please give Month/year and outcome and facilitator Please confirm that all parties have given explicit consent for us to contact them yes Date consent was given if different to referral date: Were any parties particularly resistant? (If so please state who and last contact)
