Child / Young Person Details

  • Contact Details
  • Child / Young Person Details
  • Main Reason For Appeal
  • Summary

Contact Details


Address Line 1

Address Line 2


Post Code


Telephone number

Child / Young Person Details


Date of Birth


Date of letter from local Authority advising of their decision


Refusal to Assess for an Education, Health & Care Plan

You now have 2 options

Please select one

If you have checked this box, a mediator will call you within 5 days of you completing this online form. In the boxes below, please select all suitable days and times for you to receive a call (please note, the mediator cannot speak to you while you are driving and will agree an alternative time to call back).

If you have checked this box, we shall issue you with a certificate within 2 working days of receiving this form. You then have 30 days from receipt of the certificate to lodge your appeal. There is no more for you to do on this form other than going to the SUBMIT button at the end.

Please choose best day to contact you

Which Time of Day is best to contact you

Agreement to Dispute Resolution and Mediation

Agreement to Dispute Resolution and Mediation
By accepting this Agreement, you are saying that you know about and agree to the following:

  • You have decided to discuss your case in detail with the independent mediator.
  • You give permission for the mediator to share the details of your case, as she has been given to understand it by you, with the Local Authority with the purpose of seeing if your case can be resolved before a mediation meeting becomes necessary.
  • You understand you will not be copied-in to conversations between the mediator and the Local Authority.
  • You accept that these Dispute Resolution conversations are confidential (cannot be used as evidence elsewhere) unless agreed otherwise between all parties. The exception to this is anything required by law, for example, if someone is at risk of harm, this cannot be kept secret.
  • The mediator will let you know if there might be a ‘conflict of interest’ in other words, if anyone involved in the Dispute Resolution or Mediation is known to them outside of the mediation process.
  • The mediator is not on anyone’s side but is working to help both sides reach agreement.
  • The mediator will not give legal advice.
  • The mediator will not make any decisions but both the parent (or young person themselves) and the Local Authority have the power to make decisions about arrangements that are agreed.
  • Anyone can ask to stop the Dispute Resolution or Mediation.
  • Unless the mediator commits fraud or does not do something they are meant to, no one can make the mediator responsible for the outcome of Dispute Resolution or Mediation. And if someone chose to try and do this anyway, they would have to pay for any cost to the mediator/mediation service.
  • If you and the Local Authority reach agreement, the mediator will summarise the outcome in writing to both parent and Local Authority on a Memorandum of Agreement which you are both required to accept in writing (by email) before it becomes effective.
  • Should either party request changes to the Memorandum before signing, the mediator will correct factual errors provided the precise wording to be used is provided and agreed by both parties. Agreements made between the parties after mediation cannot be included.
  • Should the Dispute Resolution not resolve the dispute, the Mediation Service will organise a mediation meeting via Zoom video conference or face to face at an agreed venue where this is preferred and permitted. This meeting will be with the Senior Special Needs Officer, the parent and a mediator (not necessarily the Dispute Resolution mediator). This will be a confidential meeting, which includes audio recordings, which are not permitted at all without express consent of all parties.

The mediator and Senior Special Needs Officer will also sign up to these terms at the next stage in the process, a record of which is kept on our files.

I have read and agree to the above

Releasing Potential Mediation
7 Kingscroft Court
Charity No: 1097440
Company No: 4622100

07764 326384 (Mediation Helpline)