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We cordially invite you to join our global registry of elder mediators:

Fill out this questionnaire on the web

. Please include a photograph if you have one. A brief description of your background will be placed next to your photograph on our "Locate a Mediator" page. This description is taken from the section of the questionnaire that reads: "OVERVIEW OF BACKGROUND (PRIMARY PROFESSION, ETC. MAXIMUM 50 WORDS)"

Once your application has been reviewed, you will be notified by email that your qualifications have met our two guidelines for the registry, a 40-hour mediation course, and mediation of at least five disputes of any type.

Then please pay the $60.00 annual listing cost:

mail a check to "EldercareMediators.com , LLC" -

Janet Mitchell, 7503 Hosler Rd., Leo, IN 46765,

or pay online via

You will be notified when your listing is online. Welcome aboard!
Please fill in all information and click "SUBMIT", thank you.

A.
BASIC INFORMATION:

LOCATION(S):
"I WILL MEDIATE IN THE FOLLOWING LOCATION(S)":
LIST AT LEAST ONE STATE, THE STATE WHERE YOUR OFFICE IS LOCATED, AND ANY ADDITIONAL STATES OR METROPOLITAN AREAS OUTSIDE OF
THE FIRST STATE LISTED. NOTE YOUR TRAVEL COSTS.

YOUR NAME:
BUSINESS NAME:
PHOTO (ATTACH):

ADDRESS:
PHONES:
FAX:
EMAIL:
WEBSITE:
LANGUAGES SPOKEN FLUENTLY:
	English Others:
FEES PER HOUR & OTHER FEES (EG. TRAVEL):

DO YOU HAVE MEDIATOR MALPRACTICE INSURANCE?

OVERVIEW OF BACKGROUND
(PRIMARY PROFESSION, ETC. MAXIMUM 50 WORDS):

GENERAL MEDIATION EXPERIENCE (MAX 30 WORDS):

NUMBER OF MEDIATED DISPUTES (ANY KIND--MINIMUM 5 TO BE LISTED):

5-9
10-25
26-50
51-100
100-300
over 300

NUMBER OF MEDIATED DISPUTES INVOLVING HIGH-CONFLICT FAMILY MEDIATION:

5-9
10-25
26-50
51-100
100-300
over 300

ELDERCARE MEDIATION EXPERIENCE: NUMBER OF EM DISPUTES MEDIATED:

Less than 5
5 or More

NUMBER OF YEARS YOU HAVE MEDIATED:

GERIATRIC EXPERIENCE (MAX 30 WORDS):

OTHER
(EG. PERSONAL EXPERIENCE WITH FAMILY DECISIONMAKING REGARDING PARENTS, ETC. MAX 30 WORDS):

C.
EDUCATION, ASSOCIATIONS, AND LICENSES/MEDIATOR REGISTRIES:

EDUCATIONAL DEGREE(S), MAJOR(S), & INSTITUTION(S):

PROFESSIONAL ASSOCIATIONS: MEDIATION
(IF ASSOCIATION FOR CONFLICT RESOLUTION (ACR), INCLUDE WHETHER PRACTITIONER MEMBER) , GERIATRIC, THERAPIST, LEGAL, ETC. (MAX 30 WORDS):

MEDIATOR REGISTRIES/CERTIFICATION/LICENSES
(NOTE IF YOU RECEIVED ANY DISCIPLINARY ACTIONS) (MAX 30 WORDS):

D.
TYPES OF ELDERCARE MEDIATION DISPUTES THAT YOU WILL MEDIATE:

CHECK ALL THAT APPLY & CHECK TYPES OF EM DISPUTES THAT YOU HAVE ALREADY MEDIATED:
WILL	HAVE
		Quality of Life
		Housing
		Car Keys, Driving & Transportation (limitations on driving, testing, transportation to medical appointments, friends, social events & church)
		Caregiving (division of duties, relief for caregivers, level of care needed, planning vacations for parents & caregivers)
		Financial Decisions
		Working through Family Fights (improving sibling relationships, learning communication skills, & working as a team)
		Geriatric Assessment
		Wills, Trusts & Estates (planning, distribution of assets, & resolution of family disputes)
		Division or Sale of Farms, Businesses & Property
		Powers of Attorney & Avoiding Guardianship
		Health Care Decisions
		Emergency Decisions
		Planning Ahead for End of Life Decisions (funeral planning & Advanced Directives (Living Wills/Life Prolongation, organ donation preference, appointment of health care representatives)
		Resident Injury, level of care, & Wrongful Death
Other (List):
WILL
HAVE
		All of the Above

E.
MEDIATION TRAINING:

TRAINING IN BASIC MEDIATION
(MINIMUM 40 HOURS OF GENERAL MEDIATION TRAINING):
NOTE TYPE (FAMILY, CIVIL, COMMUNITY MEDIATION OR OTHER, TITLE(S), TOTAL NUMBER OF HOURS, TRAINERS)
(MAX 30 WORDS):

TRAINING RECEIVED IN ELDERCARE MEDIATION:
NOTE TITLES, TOTAL NUMBER OF HOURS & TRAINERS (MAX 30 WORDS):

TRAINING IN DOMESTIC VIOLENCE: NOTE TITLE(S), TOTAL NUMBER OF HOURS & TRAINERS (MAX 30 WORDS):

SUMMARY OF OTHER ADVANCED MEDIATION TRAINING:
NOTE TITLE(S), TOTAL NUMBER OF HOURS & TRAINERS (MAX 30 WORDS):

WERE YOU A TRAINER FOR ANY NOTED ABOVE?
IF SO, LIST HOURS:

F.
MODELS AND PROCEDURES USED AS A MEDIATOR:

MODEL(S) OF MEDIATION USED PRIMARILY:
	FACILITATIVE TRANSFORMATIVE DIRECTIVE

**TYPE(S) OF MEDIATION SESSION USED (NOTE ALL YOU USE, THEN FOR EACH CATEGORY, LIST YOUR LEVEL OF EXPERIENCE: LOW, MEDIUM, HIGH):**
NONE LOW MEDIUM HIGH	IN-PERSON ONLY
NONE LOW MEDIUM HIGH	IN-PERSON WITH SOME PARTICIPATION BY CONFERENCE CALL
NONE LOW MEDIUM HIGH	MEDIATION BY CONFERENCE CALL
NONE LOW MEDIUM HIGH	ONLINE DISPUTE RESOLUTION (MEDIATION WITH VIDEO COMPONENT)

Janet Mitchell, J.D.
7503 Hosler Rd.
Leo, IN 46765

260-483-7660
FAX: 260-483-7660
JanetMitchell1@aol.com