The information in this form helps determine whether the young person/family is suitable to engage with Mediation services.  Please complete this form in full. All information is mandatory unless stated otherwise. Any missing information could result in the referral being automatically declined.  By submitting this form, you agree to respond to any requests for clarification information within 2 working days.   

Please note that mediation can only occur if the home is safe for the young person. 

At the start of each section, we explain why we collect that particular piece of information and with whom we share it. This is important to ensure everyone understands how we use their personal information. Please read this out loud to the person you are referring to so they are clear. 
In addition, please share the following statement with all people referred for support: 

When we receive referrals for Reconnect, we collect your personal and sensitive information. You have a right to know who has access to your personal information and with whom it is shared. 

The Reconnect service will ask for various pieces of information to: 

This is to help us improve the service and better understand who we help. 

We take good care of your details, and they are always safe with us. We store all this information on our secure database. 

For more information, contact: dataprotection@depaulcharity.org.uk or read our Privacy notice https://www.depaul.org.uk/data-protection-and-privacy-statement/