Elder Mediation Referral Checklist
Your contact info, elder contact info, &, if different, your client's contact info.
Your business or
agency name, street
address, city, state &
ZIP
If elder is NOT your
client, name of your
client, his/her street
address, city, state &
ZIP, telephone number
& e-mail address
No
Other parties names, contact info & whether expecting a call from Pat.
1. What are the general issues in this situation?  Select all that apply:
2. Is there an issue that needs to be decided immediately on an emergency basis?
Yes                                            No                                   Don't know
3. Is there a conflict among family members or relevant individuals over any aspect of
elder's care or decision-making?
Yes                                            No                                   Don't know
4. Does the elder object to the proposed care/decision-making plans or to a particular
decision-maker or caregiver?
Yes                                            No                                   Don't know
5. Describe any other areas of difficult joint-decision making or conflict you have
identified:
6. Are there allegations of elder abuse?
Yes                                            No                                    Don't know
7. Is anyone planning or threatening a court action?
Yes                                            No                                    Don't know
8a. Does the elder have any physical or mental impairment that would interfere with
his/her ability to participate in the mediation?  (If yes, please elaborate in the
comment section below)
Yes                                            No                                     Don't know
8b. If so, are there modifications or accommodations that would enable the elder to
participate?  (If yes, please elaborate in the comment section below)
Yes                                            No                                      Don't know
9a. How well can the client communicate?  
Well              Adequately               Poorly               Not at all                 Don't know
9b Are there auxiliary aids or services that would enable the client to communicate
more effectively?  (If yes, please elaborate in the comment section below)
Yes                                            No                                       Don't know
10. From your perspective, if a mediation occurs, who should be present?  (Please
indicate what role, if any you or your agency/business would play .)
11.What is the elder's ability to participate in mediation?  Consider the following
factors: a) understanding of issues, b) understanding of who the parties are,
c) ability to generate options, d) ability to listen and comprehend others,
e) ability to assess options, f) expression of consistent opinion,
g) ability to make and keep agreements
Will need significant
assistance
12. Comments: Please elaborate on your answers above or give any other thoughts or
recommendations that would be useful to the mediator.


Make a Referral for Elder Mediation Services
EMS Home Page
About EMS & Pat E. Medford
Agreement to Mediate Form
EMS Services, Fees & Terms
Frequently Asked Questions
Request to begin elder mediation process
Make a referral for elder mediation
Resources: websites, books & articles
Send an e-mail to Pat
I can help you "turn over a new leaf" and communicate more effectively!
1. Review your case with reference to the information requested on the Elder Mediation
Referral Checklist (below).

2. If you are unsure whether this situation would be appropriate for elder mediation, contact
Pat and discuss the case very generally, without identifying information.  Initial consultations
of up to 30 minutes are FREE.

3. When you have determined your case may be appropriate for referral, tell your client that
you think elder mediation would be helpful in solving the problems he/she is dealing with and
resolving the conflict.  Suggest he/she give elder mediation a try; obtain his or her
permission to contact Elder Mediation Services, sharing a synopsis of the situation and
requesting Pat contact him or her with information about elder mediation.  

4. Call Pat with referral details or e-mail the completed Elder Mediation Referral Checklist to
Pat at Elder Mediation Services.  [See Home page for contact information]

5. Notify your client and, if appropriate, relevant family members, that Pat will be contacting
them to provide information and answer any questions as to how to proceed with the elder
mediation process.
Your name
Telephone number:
E-mail address:
Name of elder:
Elder's telephone #:
Elder's street address,
city, state & ZIP
Your client is expecting a call from Pat.
Yes
Other party a):
expecting Pat to call
Other party b):
expecting Pat to call
Other party c):
expecting Pat to call
Other party d):
expecting Pat to call
Other party e):
expecting Pat to call
Case Assessment
Housing/Living Arrangements
Safety
Caregiving
Healthcare Planning
Medical Treatment
Financial management
Consumer Issues
Estate Planning & Probate Matters
Guardianship or Conservatorship Issues
Social Life & Activities
Spirituality & Aging
End-of-Life Decisions
Ongoing Relationships
Able to participate with
no or some assistance
Unable to participate
 Don't know
503-233-9033

E-Mail:

eldermediationservices
@comcast.net