At any point if you would like to switch to having a phone conversation with one of our team, this is easy to do - phone us on 0800 77 44 20.

Please note you can you use the 'save and complete later' button, and your entries will be saved for 7 days. Please ensure you correctly enter your email address before saving.

If you wish to fill this form out in Te Reo Māori, please click here.

Funding:

Everyone is eligible for a subsidised service and FDR mediation is free if you qualify for government funding. There are different thresholds which will determine what funding you qualify for.

Do you wish to read the funding thresholds? *

YesNo

Click here to see further information on our website regarding funding.

Do you appear to be eligible for a funded service? *

YesNo

If No - The total cost per person is $448.50 for up to 12 hours of FDR services for each family dispute. As you do not qualify for funding, our team can talk with you about payment options after you have submitted your online application. There is no cost to apply for FDR.

Would you like to provide your evidence of funding now?

Yes, I am happy to provide this nowNo, I would like to provide this at a later date

If Yes - Click here to download the Funding Declaration Form (FDF), complete this and upload this below:

Upload your completed FDF here:

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Allowed file types: pdf, docx, jpeg, jpg, png, txt, xlsx, rtf, tif, tiff, odt

Please upload evidence to show that you are eligible for a funded service:

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This can be any one of the following: a photo of your Community Services Card, a letter from WINZ, proof of legal aid grant, a copy of your most recent tax return, a payslip or letter from your employer, or your last 3 months of bank statement.

About you:

First name:

Last name:

Email address:Please check you have entered this correctly.

Phone - mobile:

Phone - home:

Phone - work:

How would you prefer to receive correspondence?

How would you prefer us to contact you?

Physical address:

Postal address (if not the same as above):

Date of birth:

Gender:

First language:

Ethnicity:

Do you have a preferred time for us to contact you?

YesNo / Anytime

If you have a preferred time for contact, please select below:

Do you have a preferred contact number for the time selected above?

YesNo

If Yes - which one:

MobileHomeWork

Do you have an existing FDR case?

YesNo

Do you know your FDR #?

YesNo

Please enter your FDR # here:

Where did you find out about us?

Please specify:

Further Information:

Children's details:

Full name:

Relationship to child:

Gender:

Date of birth:

School:

Use my address:

Other parent/caregiver's details:

First name:

Last name:

Phone:

Email address:

Address:

Gender:

First language:

Additional people:

Is there anyone else that should be included in the mediation process?

YesNo

This could be grandparents, stepparents, foster parents etc

Relationship to the child/children:

First name: *

Last name: *

Mediation objectives:

We would like to understand what matters to you and the current challenges you are facing.

Please select any objectives below that you are happy for us to share with the other parent or caregiver. Please note that this is the only part of the questionnaire that will be shared with the parent or caregiver. This is so that they are aware of your reasons for wanting to attend mediation.

I want to come to mediation to talk about - please select one or more objectives:

Further details:

Tell us more about your family situation:

Are you, or have you been, involved in Family Court Proceedings?

YesNo

Family Court:

No live application at presentLive application at present

Details:

Parenting orders:

No Parenting Order In placeParenting plan / arrangementParenting Order in place

Details:

Have you been directed by a judge to attend FDR? *

YesNo

Can you please upload a copy of the direction to attend FDR?

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Allowed file types: pdf, docx, jpeg, jpg, png, txt, xlsx, rtf, tif, tiff, odt

If you know your FAM Court reference number please list this here:

Lawyer for Child

Lawyer for Child representing Child(ren)Lawyer for Child not appointed

Details:

Oranga Tamariki *

Never involvedInvolved nowFile closed

Details:

In order for us to ensure that FDR mediation is the best process for your family we need to ask some questions about family violence. If at any point you would rather go through these questions on the phone with one of our team, please call us on 0800 77 44 20.

In some unhealthy relationships, one person may use their power over another. This can affect how well you and your ex-partner communicate and cooperate as you separate. It can show up as abusive behaviours. For urgent help on family violence please click here:

Relationship background:

To help us set up your mediation, we like to get an understanding of your relationship history with the other parent or caregiver.

How would you describe communication between you both about the child(ren)

Can you please tell us how long you were together as a couple?

When did you separate?

Was there abuse or abusive behaviour within your relationship?

Are you worried about actions or behaviours towards yourself or your children?

Has the use of drugs and/or alcohol been an issue for either of you? *

YesNo

If Yes - Can you tell us more about this?

Have the Police ever been involved with your family? *

YesNo

If yes - Can you tell us more about that?

Have either of you been issued with a Protection or Police Safety Order (PSO)? *

YesNo

If Yes - Can you please tell us about that?

Mediation set up:

Preparation for Mediation (PFM)

Part of the FDR process includes Preparation For Mediation. Would you like to participate in this? *

YesNo

Click here to learn more about Preparation for Mediation

Do you have any cultural requirements for mediation?

Are you ok both being in the same room for the mediation?

Do you wish to have a support person present?

Do you have a preferred mediator or skill set?

Do you have a preferred location for mediation (Geographical location or Online)

Is there anything else we need to know to set up mediation for you?This could be: the need for a translator, the preference to mediate via Zoom, your availability to mediate, any urgency about accessing mediation etc

Referrals:

Parenting Through Separation (PTS)

Click here to learn more about Parenting Through Separation.

Have you completed a Parenting Through Separation course? *

YesNo

If yes, please provide details:

Do you wish to be referred?

YesNo

Free Legal Advice Service (FLAS) / Legal Advice

Have you had any legal advice on your family situation and your mediation objectives?

Free Legal Advice Service (FLAS)LawyerNone

Comments:

If eligible for funding, do you wish to be referred?

YesNo

Relationship Property

Fair Way can assist you in resolving any relationship property issues you might have. If you wish to know more, please click here

Do you need to reach an agreement regarding relationship property? *

YesNoNot applicable

Would you like us to contact you?

YesNo

Support & wellbeing:

Do you have any health issues that would make participating in mediation challenging for you? *

YesNo

If Yes - Is there anything that we could do to assist you with this?

How are your child(ren) coping?

What support services (if any) are your family involved with currently?

Have you ever been involved with any family violence support agency? *

YesNo

If Yes - Who?

If you have responded yes to the above we will contact you further regarding this.

Privacy

To learn more about how Fair Way manages privacy, you can read our privacy policy statement. This explains that Fair Way follows the Privacy Act 2020 when using and managing your personal information, and you have the right to know what information is held about you.

The Ministry of Justice also provide a privacy statement which you can find here.

Please note that once you have clicked submit below you will not be able to update this form without contacting us on 0800 77 44 20. If you wish to review the responses you have provided, simply click on the button labelled 'Previous' below and this will take you to the page prior. Please note that none of the responses you have provided will be lost in doing so.

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