Start Afresh Mediation

Before your MIAM

Please complete this form ahead of our meeting. It will help you reflect on your situation and ensure we can use the session time effectively.

The information you provide gives me a clear picture of your circumstances and family context. Please answer as fully as you can. If a question doesn’t apply to you, simply leave it blank.

Your details

Full name

Date of birth

Phone number

Email address

Home address

Do you have any additional needs I should know about? e.g. health or interpreting needs

The other participant’s details

Full name

Date of birth if known

Phone number

Email address

Home address

Your relationship

Date of marriage / civil partnership if applicable

Date you started living together

Date of separation

Date of divorce / dissolution if applicable

Do you think your relationship has come to an end permanently?

Yes No I’m not sure

Children

Add a card for each child. Leave blank if this doesn’t apply to you.

Child 1

Full name

Date of birth

Any special needs? leave blank if none

Do you have parental responsibility?

Yes No

Financial overview

Just a general picture at this stage — highlights only.

This section is just to help me understand the shape of your situation before we meet — not a financial disclosure. If mediation goes ahead and money is part of what you want to discuss, we’ll gather full figures and documents separately at that point.

Do you or your partner own any property, including your home? brief note is enough — whose name it’s in, roughly what it’s worth

Any savings, investments, or business interests worth mentioning?

Any pensions? roughly how many, and pension provider name, if you know

Any significant debts or loans, other than a mortgage?

A few more questions

Would you like to agree a clean break?

Yes No Other

Would you like to request or pay spousal maintenance?

Yes No

Do you have a will in which the other participant is a beneficiary?

Yes No

Are you receiving any benefits other than child benefit?

Yes No

MIAM Questionnaire

Before your MIAM

Your details

The other participant’s details

Your relationship

Divorce or dissolution

Children

Arrangements for the children

Financial overview

A few more questions