Client Information Form For Elder Mediation

PLEASE READ THESE INSTRUCTIONS CAREFULLY
This form can be saved after the completion of any page by clicking on 'Next'. This will save it so that you can come back and complete it later, but you must be using the same device and browser. Also, you must avoid clearing your browser's cache. After submitting it, a copy will automatically be sent to the email address you provide for yourself.
This form is confidential. Information will not be shared with anyone outside of Start Mediation without your permission.

If you are not the elder person this matter concerns, provide any of their known details here.
Name of Elder Person
Prefix First Last
Date of Birth
DD slash MM slash YYYY
Phone
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your relationship to them.
Do you believe the elder has the capacity to make decisions about their future? If not, please expalin why.

Your details
Title*
- Mr
- Ms
- Mrs
- Miss
Name*
First Last
Date of birth*
DD slash MM slash YYYY
Your home postal address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Your email address:*

This is the address to which a copy of this form will be automatically sent.
Primary phone number*
Secondary phone number
Do you have any disabilities which affect where you can meet?
- Yes
- No
If yes, please provide details and any facilities needed.
Have you had any counselling or therapy relevant to this matter?*
- Yes
- No
If applicable, please provide brief details:

Other information
Please provide the name, age, relationship to you, town of residence and phone number of any others you feel should be involved in any mediation. If you believe they have different views to you about the matter, please summarise them If there are no other persons, please state "none".*
Please provide brief details of the matters you want to see discussed.*
Please would you say what your aims are in coming to mediation. We appreciate that you may need to know more from the mediator(s), but it would help to have some preliminary idea of what you hope to achieve in broad terms, not in detail.*
Are there any obstacles you can think of that you believe might prevent a successful outcome to mediation.*
We meet all participants inviidually before there is the joint mediation session. What kind of confidential consultation with us would you like?*
- In person at your consulting rooms.
- In person in my home.
- Via a webcam over Skype, FaceTime or some other video link.
Today's Date*
DD slash MM slash YYYY

PLEASE READ THESE INSTRUCTIONS CAREFULLY