Application for FDR Mediation

APPLICATION FOR FDR MEDIATION


This form can be filled either by the participant or someone else on the participant's behalf, provided that the representative is authorised by the participant.


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Are you making this application because a judge has directed you to attend FDR Mediation?
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If so, when?
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Please indicate court reference number:
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Has a lawyer for the child been appointed by the Court?
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Please provide contact details of lawyer for the child::
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How did you hear about the FDR Centre?
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Please indicate the name of mediator or lawyer who referred you to FDR Centre
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Please indicate the way you found the FDR Centre*
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Full Funding Eligibility

Number of dependants* Maximum annual income** (before tax and any deductions) Maximum fortnightly income (before tax and any deductions) Maximum earnings over past 3 months (before tax and any deductions)
0 (you have no dependants) $23,820.00 $916.15 $5,955.00
1 (a dependent partner or child) $37,722.00 $1,450.85 $9,430.50
2 (a dependent partner and/or children) $54,245.00 $2,086.35 $13,561.25
3 (a dependent partner and/or children) $61,642.00 $2,370.85 $15,410.50
4 (a dependent partner and/or children) $68,882.00 $2,649.31 $17,220.50
5 (a dependent partner and/or children) $77,002.00 $2,961.62 $19,250.50
6 or more (a dependent partner and/or children) $77,002.00 plus $7,124 per extra dependant $2,961.62 plus add $274 for each extra dependant $19,250.50 plus add $1,781 for each extra dependant
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*a dependent includes a partner who has no income and all children who rely on you for financial support, whether or not they live with you. This may also include your partner’s children if you are regularly making payments for them.

**income includes wages or salary as well as any benefits, interest or income received from a trust. It does not include debts, assets or your partner’s income.

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*a dependent includes a partner who has no income and all children who rely on you for financial support, whether or not they live with you. This may also include your partner’s children if you are regularly making payments for them.

**income includes wages or salary as well as any benefits, interest or income received from a trust. It does not include debts, assets or your partner’s income.


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Based on the information above, do you believe you qualify for full funding?*
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Declaration Form for Applications for Full Funding

If you qualify for full funding and you want to get full funding for this FDR Mediation, you must complete and sign a Funding Declaration Form. You must also provide proof of your income. Your case manager will send you a copy of this form once the initial FDR Assessment is completed.]

Please note: if you qualify for full funding but you don’t submit your Funding Declaration Form, you will have to pay $448.50 for FDR Mediation.


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APPLICANT


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Legal First Name*
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Middle Name
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Surname*
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Preferred Name (if different from above)
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Email Address*
Please enter a valid email address
Please enter a valid email address
It is essential that we have a valid email address for you, please enter your email address again here to confirm.
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Mobile Number*

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Phone Number
Please include your area code
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Residential Address*
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City and Postcode*
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Region*
  • - select option -
  • Auckland
  • Bay of Plenty
  • Canterbury
  • Gisborne
  • Hawke’s Bay
  • Manawatu-Wanganui
  • Marlborough
  • Nelson
  • Northland
  • Otago
  • Southland
  • Taranaki
  • Tasman
  • Waikato
  • Wellington
  • West Coast
  • Overseas
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Gender*
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Date of Birth*
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Ethnicity Applicant*
Choose from dropdown
  • - select a option -
  • NZ European
  • Maori
  • Tongan
  • Samoan
  • Other Pacific Islands
  • Chinese
  • Japanese
  • Korean
  • Filipino
  • Fijian
  • Indian
  • Other Asian
  • Other Southeast Asian
  • Other European
  • Middle Eastern
  • Latin American
  • African
  • Other
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Your relationship to the child(ren)?
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THE OTHER PARTICIPANT/S


You must provide some form of contact details for the other participant. Otherwise the FDR Centre will not be able to process your application.


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Field is required!
Legal First Name*
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Field is required!
Middle Name
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Field is required!
Surname*
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Field is required!
Preferred Name (if different from above):
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Field is required!
Email Address (other party)
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Mobile Number

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Phone Number*
Please include area code
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Field is required!
Residential Address
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Field is required!
City and Postcode
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Field is required!
Region*
  • - select option -
  • Auckland
  • Bay of Plenty
  • Canterbury
  • Gisborne
  • Hawke’s Bay
  • Manawatu-Wanganui
  • Marlborough
  • Nelson
  • Northland
  • Otago
  • Southland
  • Taranaki
  • Tasman
  • Waikato
  • Wellington
  • West Coast
  • Overseas
  • Other/unknown
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Field is required!
Gender*
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Field is required!
Date of Birth (other party)*
To correctly identify the other participant, date of birth is required
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Field is required!
Ethnicity*
Choose from dropdown
  • - select a option -
  • NZ European
  • Maori
  • Tongan
  • Samoan
  • Other Pacific Islands
  • Chinese
  • Japanese
  • Korean
  • Filipino
  • Fijian
  • Indian
  • Other Asian
  • Other Southeast Asian
  • Other European
  • Middle Eastern
  • Latin American
  • African
  • Other
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Field is required!
Their relationship to the child(ren)?
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**If there are more than two parties, click on the "plus" sign button on the right to add another participant. Please note that a support person is not considered a participant for the purpose of this form.
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CHILDREN INVOLVED


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How many children are involved in this FDR Mediation?
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CHILD ONE


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Legal First Name*
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Child's Surname*
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Child's Preferred Name (if different from above)
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Date of Birth*
If the child is unborn, please insert due date
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Gender*
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Who is the child currently living with?*
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Special Health or Other Needs
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Field is required!

CHILD TWO


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Legal First Name
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Child's Surname
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Child's Preferred Name (if different from above)
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Date of Birth*
If the child is unborn, please insert due date
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Gender
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Who is the child currently living with?
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Special Health or Other Needs
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Field is required!

CHILD TWO


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Legal First Name
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Child's Surname
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Child's Preferred Name (if different from above)
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Date of Birth*
If the child is unborn, please insert due date
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Gender
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Who is the child currently living with?
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Special Health or Other Needs
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CHILD THREE


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Field is required!
Legal First Name
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Child's Surname
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Child's Preferred Name (if different from above)
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Date of Birth*
If the child is unborn, please insert due date
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Gender
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Who is the child currently living with?
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Special Health or Other Needs
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Field is required!

CHILD TWO


Field is required!
Field is required!
Legal First Name
Field is required!
Field is required!
Child's Surname
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Field is required!
Child's Preferred Name (if different from above)
Field is required!
Field is required!
Date of Birth*
If the child is unborn, please insert due date
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Gender
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Who is the child currently living with?
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Special Health or Other Needs
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Field is required!

CHILD THREE


Field is required!
Field is required!
Legal First Name
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Field is required!
Child's Surname
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Field is required!
Child's Preferred Name (if different from above)
Field is required!
Field is required!
Date of Birth*
If the child is unborn, please insert due date
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Gender
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Who is the child currently living with?
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Special Health or Other Needs
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Field is required!

CHILD FOUR


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Field is required!
Legal First Name
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Field is required!
Child's Surname
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Field is required!
Child's Preferred Name (if different from above)
Field is required!
Field is required!
Date of Birth*
If the child is unborn, please insert due date
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Field is required!
Gender
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Field is required!
Who is the child currently living with?
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Field is required!
Special Health or Other Needs
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Field is required!
Click on the green "PLUS" sign on the right to add more children to this FDR Mediation.
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Specialist Selection


*Please note: You do not need to select a particular mediator, in most cases our clients prefer us to select the most appropriate available person.

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Do you have a preferred mediator?
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I/we would prefer to be referred to the following person(s)
*Please note: If the person you have selected is unavailable we will appoint the most suitable available person to handle your case.
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All of the parties are in agreement to the above preferences?
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Issues and Aims




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Issues you would like to resolve*
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Other:
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Aims
Please tell us a little about your aims and objectives in coming to the FDR Centre.
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Does the other participant know that you want to have these issues resolved by FDR Mediation?
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AVAILABILITY AND SPECIAL REQUIREMENTS

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When can we contact you?
Please indicate the best time for us to contact you about your application.
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Availability for FDR Mediation
Are there any days/time to avoid? (Complete if there are any dates or times that you will be unavailable for mediation.)
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Special Facilities or Requirements
Are there any special accessibility requirements? *
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Is an interpreter required? *
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Are there any other special requirements we should be aware of? *
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If you answered yes to any of the above, please provide more detail as to the requirements below:
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If suitable, would you consider attending mediation by videoconference?
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Privacy information for customers

To provide you with our service the Ministry of Justice requires us to collect personal information about you, including:

- name
- contact information
- demographic information
- funding eligibility
- disputes you are involved in concerning the care of children
- what out-of-court family justice services you access and their high-level outcomes.

We record and store your information in a secure database that is managed by the Ministry of Justice.

We collect your personal information to track and report on our services to the Ministry of Justice, and to make sure that other family justice service providers have access to relevant information if providing services to you.

Your information may be used by the Ministry of Justice for reporting and research purposes. When used for this purpose, your information will not identify you. The Ministry of Justice may also contact you to invite you to participate in research, for example online surveys. This will be voluntary.

Besides family justice service providers and Ministry of Justice staff, we may disclose your personal information to third parties when we believe in good faith that we are required to do so by law.

It is not compulsory for you to provide the Ministry of Justice with your personal information, but if you do not provide all the information requested, we may not be able to provide you with a service.

You have the right to ask for a copy of any personal information we hold about you, and to request correction of that information if you think it is wrong. To request a copy of your information, or to have it corrected, contact:

Provider and Community Services
Ministry of Justice
SX10088
WELLINGTON
Email: RMS.Family@justice.govt.nz


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Please confirm that the applicant has read, understood, and agrees with the Privacy Statement above:
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