NAME
EMAIL
 
 
 
Vancouver Seniors Survey
Q1
    
1.I am responding to this survey as:
Yes No
1.The Main Caregiver
2. The Senior over age 65
3. Other Family Member
4. Non-Relative
5. Other (please specify)
   
 
Q2
    
2. Our family has had discussions regarding the following topics:
 Yes No
1.Living Arrangements as our parent(s) age.
2.Care arrangements as our parent(s) age.
3. Finances and how these apply to living and care arrangements.
4. Health Directives
5. Will and Estate Decisions
6. Other
   
 
Q3
    
3. I have concerns about dealing with a Senior with the following health issues;
 Yes No  
1. Alzheimers
  
2. Diabetes
 
3. Respiratory Disease
  
4. Self Neglect
 
5. Other (please specify)
     
 
Q4
    
4. I fear that there appears to be the following types of abuse happening to the Senior;
 Yes No
1. Physical Abuse: slapping, kicking, shoving, burning
2.Sexual Abuse:Engaging in verbal or non-verbal behaviour of a sexual nature and/or physical sexual contact in which the senior does not have the ability to express or engage in own their own accord.
3. Psychological Abuse: Humiliation, isolation, intimidation

4. Financial Abuse: Misuse of seniors money,property or other possessions through fraud, forgery or extortion
 
Q5
    
5.The Senior person refuses to consider the following:
Yes No
1.Giving up their Driver's Licence.
2.Look at options for living arrangements.
3. Wear a Medical Device.
4. Discuss their financial and health directives with their children.
5. Other (please specify)
   
 
Q6
    
6. We are interested in learning more about Senior issues and Elder Mediation through the development of the following Products &/or Services
 Yes No
1. Taking part of a family conference.
2.Teleseminar: Small Education Segment over the telephone
3. Webinar: Education segment uploaded from your computer

4. Group Discussion: Using Telephone and computer
5. Other: (please specify)
   
 
Q7
    
7. I feel that the Main Caregiver is faced with the following challenges;
 Yes No
1. Other family members not providing physical support.
2.Other family members not providing financial support.
3. Other family members not providing emotional support

4. Looks physically and mentally exhausted
5.Possible signs of Depression
6. Other: (please specify)
   
 
Thank you for completing the Seniors Survey. Kindly fill out the following email form and you will receive
"Top Ten Conflict Topics Experiences by Seniors and their Families" and automatically join my mailing list.
 
Email:
 
 
 
 
 



Vancouver Mediation
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Family Mediation

My role as an Elder Mediator is to assist elders with wills & estates to ensure that the elder's needs are met and the family understands these needs.
 

Senior Mediation
My role as an Elder Mediator is to assist elders with wills & estates to ensure that the elder's needs are met and the family understands these needs.
 
 
 
 
 
 
 
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