Request mediation on behalf of someone else

If you want to request mediation for someone else, fill in the form below.

To request mediation for yourself, fill in the request mediation for yourself form.

Required fields are marked with an asterisk (*).

Referrer details

Complete this section if you are requesting mediation on behalf of someone else

Given name *

Family name *

Daytime phone number *

Email address *

Organisation

Position

Participant A

This is the person requesting mediation.

Given name *

Family name *

Daytime phone number *

Email address

Postal address We need their email or postal address to send them updates about their case

Have they requested an interpreter?

Preferred language *

Have they agreed to this mediation request? *

Participant B

This is the person Participant A would like to mediate with.

Given name *

Family name *

Daytime phone number

Email address

Postal address We need their email or postal address to contact them about the request for mediation.

Have they requested an interpreter?

Preferred language *

Have they agreed to this mediation request?

Dispute summary

Tell us about the dispute.

Summary

Privacy statement

The Community Justice Centre (CJC) is a service of the Northern Territory Government Department of the Attorney-General and Justice.

The CJC respects your rights to your privacy. The information you submit in this online request will be held by the CJC for the purpose of providing a mediation service. All information is collected, stored, used and disclosed in accordance with the information privacy principles contained in the Information Act 2002. To find out more, read the Act or go to the Office of the Information Commissioner NT.

Read the full privacy statement.

For more information, contact the CJC on 1800 000 473.

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