Elder Mediation Questionnaire

This questionnaire is for our clients and prospective clients and will help us better understand your situation. Should you choose to enter into a mediation agreement, this information will help us develop a plan for resolution. Although strongly recommended prior to engaging in mediation, filling out of this questionnaire is voluntary.

All information furnished through this questionnaire or in telephone contact with ELDEResolutions will be considered as confidential information and will not be shared with other parties or anybody other than ELDEResolutions partners or staff without your consent. This information is treated as the first stage of a voluntary mediation process for the purposes of confidentiality of the information even if you choose not to participate in mediation. Should you have any questions about this confidentiality policy or about the process of mediation, please contact us at 303/268-2280.

Date
   
Your Name
Your Phone #
Your e-mail address
Your mailing address
Your City/State/Zip
Name of elder(s) involved
Your relationship to elder(s) involved (i.e., daughter, son, neighbor, niece, guardian, facility administrator)
Living Situation of elder(s) (i.e., own house, living with family member, assisted living facility, nursing home, other)
 
City/State of elder(s) involved


Please answer these questions for each of the other parties you believe should be involved – may include family members, professionals, advocates or others

Name
Relationship to elder (i.e., daughter, son, neighbor, niece, guardian, facility administrator)  
Location (City/State or Country)
Do you believe this person would be willing to be involved? YES/NO/Don‘t Know  
Do you believe that this person would be willing/able to pay their share of the cost? YES/NO/Don‘t Know  
 
Do you believe this person is essential to the process? YES/NO/Don‘t Know  
Comments




1. Describe the nature of the conflict/potential conflict.
2. Prioritize list the issues as you see them and prioritize them as the their importance to you. It is OK if several issues have equal importance.
3. Do you see any areas of common agreement between all (or some) of the parties in this dispute? Please explain.
4. Are there any physical limitations or medical issues that we should know about with you or any of the parties?
5. Have there been any attempts to resolve conflict? If so, what were those efforts and what were the outcomes?
6. Any additional information you would like to share about this dispute?
303/268-2280
Located in Denver, Colorado