Elder Mediation Intake Form

Thank you kindly for filling out the below intake form.
Please complete this form at least one day before our scheduled appointment.

Today's date

First Name

Last Name

Phone

Address

City/Town

Postal Code

Full name of family members involved and your relationship. (e.g. spouse, child, parent)

Other potential participants: Full name of any other potential participants in mediation (such as a friend, neighbors, guardians, facility administrator, health care professionals, lawyers)

What is your current living situation (e.g.

Any medical issues or physical limitations regarding the older adult or other potential participants in mediation?

Why are you seeking mediation?

What issues are important to you and why?

What concerns would you like to share with me at this time?

I acknowledge that anything discussed during my first initial interview and any further proceedings with Melanie Mueller Mediation is kept strictly confidential, unless any potential harm to myself, my children or any other person is disclosed. In such a case I am aware that Melanie Mueller Mediation has a legal obligation to report any safety concern to the responsible agencies.

Thanks for submitting!

Melanie Mueller Mediation

Elder Mediation Intake Form

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