Aboriginal Mediation Service Referral Form

Aboriginal Mediation Service (AMS) Referral Form
Please complete this form to participate in mediation offered by the Aboriginal Mediation Service if your matter is deemed suitable.

What is mediation

Mediation involves people willingly coming together to talk about their conflict and trying to reach an agreement that everyone can live with.

Mediation is facilitated by qualified mediator/s. The mediator is a neutral third party who helps the participants discuss the problem and find solutions. While the mediator guides and supports the process, it is up to the participants to agree on the outcomes and make them work.

How it works

Once the mediation referral form is submitted the Aboriginal Mediation Service Case Manager conducts an in-depth intake and assessment process with each party which helps to determine:
- Who is involved.
- The nature and scale of the conflict.
- Willingness to engage.
- Participants’ ability to commit to outcomes.
- Suitability for mediation.
If mediation is suitable, the AMS will also provide further information on:
- The mediation process.
- Confidentiality.
- Possible options for scheduling the mediation.
Confidentiality

It is important for anyone engaging with the AMS to understand that their information is confidential and protected.

Any contact you have with the AMS is confidential in nature. The AMS will not use any information obtained to your disadvantage.

Costs

The cost of the Mediation with Aboriginal Mediation Service is free for participants.

Help and contact

For further information or if you need help, contact the Aboriginal Mediation Service on 61 8 9264 6176 or 1800 045 577.

Participant A
Full name - Participant A*

First NameLast Name
Aboriginal/Torres Strait Islander*

Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal and Torres Strait IslanderNo
Mediation

Initiated mediationTo be invited
Participant A - Address*

Street Address Line 1

Street Address Line 2

SuburbState

Postcode
Participant A's Phone Number*

Area CodePhone Number
Participant A's Email
Enter a valid email address

Participant B
Full name - Participant B*

First NameLast Name
Aboriginal/Torres Strait Islander*

Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal and Torres Strait IslanderNo
Mediation

Initiated mediationTo be invited
Participant B - Address*

Street Address Line 1

Street Address Line 2

SuburbState

Postcode
Participant B's Phone Number*

Area CodePhone Number
Participant B's Email
Enter a valid email address
Is there another participant?*

YesNo

Participant C - if relevant only
Full name - Participant C

First NameLast Name
Aboriginal/Torres Strait Islander

Yes - AboriginalYes - Torres Strait IslanderYes - Aboriginal and Torres Strait IslanderNo
Mediation

Initiated mediationTo be invited
Participant C - Address

Street Address Line 1

Street Address Line 2

SuburbState

Postcode
Participant C's Phone Number

Area CodePhone Number
Participant C's Email
Enter a valid email address

Aboriginal Mediation Service (AMS) Referral Form

What is mediation

How it works

Confidentiality

Costs

Help and contact

Referrer’s details

Participant A

Participant B

Participant C - if relevant only

The Dispute