MEDIATOR PANEL APPLICATION FORM

THE INFORMATION YOU SUPPLY ON AND WITH THIS FORM WILL BE TREATED IN CONFIDENCE.

Section 1 Personal details

Title Last Name:

First Names:

Address:

Postcode:

Home Telephone Number:

Work Telephone Number:
Mobile Telephone Number:

E-mail address:

Are you eligible to work in the UK? Yes No

All applicants are required to provide the following evidence which should be sent with
this application form to admin@scottishmediation.org.uk or by mail to Michaela Wilson,
18 York Place, Edinburgh EH1 3EP

Section 2 Evidence of Compliance with SMR Practice Standards and Essential

Selection Criteria

SMR Qualification Required Evidence

Adequate training
Mediators must have satisfactorily
completed mediation training. The
performance of the mediator during
or on completion of mediation
training must have been assessed
as satisfactory.
A letter from a mediation training provider or training certificate
must be included (can be scanned and attached as an electronic
document).
The letter should include name of training provider, and dates
training was undertaken and a statement or certificate that the
training was satisfactorily completed.

Essential Mediation Practice Letters of reference should be provided for 3 out of the last 5
Requirement mediations undertaken and must be included with this application.
The Mediation Practice (SMN will accept electronic documents).
requirement for this contract
is higher than that for entry Dates of the last 5 mediations undertaken should be supplied
to the SMR Register. below:
To meet the Essential
selection criteria, applicants 1.
must be able to provide 2
references for 3 out of the 3.
last 5 mediations undertaken 4.
and dates of the last 5 5.
mediations undertaken.

CPD A CPD log accompanied with training certificates and/or letters

A mediator will be required to plan, confirming training/ mediation supervision, monitoring, mentoring
undertake and review at least 12 or shadowing.
hours of continuing development
and support each year.
Code of Conduct By submitting this application the applicant is confirming that they
As a minimum the mediator shall will abide by the SMN Guidelines for the Practice of Mediation in
practice in accordance with the Scotland.
Scottish Mediation Register’s
Guidelines for the Practice of
Mediation in Scotland
Complaints By submitting this application the applicant is confirming that the
Any complaints about an system for addressing concerns or complaints in use for this
individual mediator or contract will be the SMNs Quality Assurance Group.
mediation process will be
submitted in writing and
reviewed by SMNs Quality
Assurance Group.

Section 3: Compliance with Desirable Selection Criteria

Year Details of Mediation or Complaints Handling Experience in the NHS or Public

Sector

Desirable Practice Standards Evidence Required

Desirable Mediation Practice Requirement
To meet the Desirable selection criteria, applicants must
be able to provide evidence that 20 mediations have been
conducted in the last 24 months.
Letters of reference should be provided confirming
that 20 mediations have been undertaken in the last
24 months and submitted with this application form.
Mediators who are employed by a mediation service
can submit a letter from their practice supervisor.
Mediators who work sometimes for a service and
sometimes as sole traders can provide a combination
of practice supervisor references and client
references. (SMN will accept electronic documents).
Section 4: Any additional information which you wish to provide in support of your
application.

Section 3: Compliance with Desirable Selection Criteria

Section 3: Compliance with Desirable Selection Criteria

Section 7 References

Please give the contact details of the referees who provided references above. SMN
may wish to contact them to verify the application and obtain additional information.
This will only be done with your prior approval.

Reference 1 Reference 2

Name:       Name:      

Their
Their Position
Position            
(job title):
(job title):

Work Work
           
Relationship: Relationship:

Organisation:       Organisation:      

Mediation Mediation
From:       To:       From:       To:      
Dates: Dates:

Address:       Address:      

           
           
           
Postcode       Postcode      

Telephone
      Telephone No:      
No:

E-mail:       E-mail:      

 Reference 4 ( Not Required but applicant
Reference 3 are invited to submit a further reference
should they so choose)

Name:       Name:      

Their
Their Position
Position            
(job title):
(job title):

Work Work
           
Relationship: Relationship:

Organisation:       Organisation:      

Mediation Mediation
From:       To:       From:       To:      
Dates: Dates:

Address:       Address:      

           
           
           
Postcode       Postcode      

Telephone
      Telephone No:      
No:

E-mail:       E-mail:      

Section 8 Declaration

I confirm that the information provided in this application is both truthful and accurate.
I have not omitted any facts that could affect my engagement as a mediator. I
understand that any false misleading statements could result in my exclusion from the
panel. I understand that any employment entered into is subject to documentary
evidence of my right to work in the UK and satisfactory references. I expressly consent
to personal data contained within this form being recorded for the purposes of
assessing suitability for the post. I understand that all application forms will be
destroyed after 6 months.

Signed: Date: