1. Applicant Information Name (Required)
(Required) Work Address
Indicate current membership and certification in any other related organizations: (Required) If 'Provincial Organizations' and/or 'Other' chosen above, please specify: The professional context of your elder mediation practice: (Required) If 'Other' chosen above, please specify: Please explain your family/elder mediation “style” or model of practice – i.e. interest based, transformative, insight, etc. (Required) Number of Elder Mediations Completed (min of 5 for certification) (Required) Provide One-Page Summary for 5 of These Completed Mediations. (Required) 2. Curriculum Vitae Curriculum Vitae (Required)
Please upload your resume outlining your education and professional qualifications and achievements.
3. Previous Certification Previous Certifications
Please attach proof of any related certification or other special certificate of concentrated training.
4. Elder Mediation Training
N.B. Please list only the hours necessary to meet the requirements. Complete Section (A) if you are not certified by a recognized accrediting body. Please enclose copies of training certificate(s) for this section.
Section A) Basic Mediation Training
Conflict resolution, mediation theory education and skills training and intercultural training.
*At least 100 hours (prior certification with your mediation organization may meet the requirements for this section)
Upload Any Training Certificate(s)
Drop files here or
Max. file size: 128 MB.
Section B) Specific Elder Mediation Training
A Minimum of 100 Hours Required (including the topics listed below)
i. Current and future profiles of seniors in your country/region; family life cycle; family dynamics; intergenerational dynamics. AT LEAST 21 HRS REQUIRED.
ii. Recognizing and responding to elder abuse & neglect. AT LEAST 14 HRS REQUIRED.
iii. Knowledge of legislation in your country relevant to elder mediation, capacity and elder abuse. AT LEAST 8 HRS REQUIRED.
iv. Identifying and dealing with power dynamics involving and affecting older people with and without capacity. AT LEAST 8 HRS REQUIRED.
v. The nature and impact of bereavement, grief and loss. AT LEAST 8 HRS REQUIRED.
vi. The impact of ageism, sexism and cultural diversity. AT LEAST 8 HRS REQUIRED.
vii. Understanding dementia & age-related diseases and how to assess, manage and accommodate capacity issues. AT LEAST 14 HRS REQUIRED.
viii. Financial & estate issues for identifying areas of concern and referral. AT LEAST 6 HRS REQUIRED.
ix. Ethics and ethical issues relevant to elder mediation. AT LEAST 6 HRS REQUIRED.
x. Facilitating and writing agreements in elder mediation. AT LEAST 3 HRS REQUIRED.
xi. Advanced Care Directives – Power of Attorney and Guardianship – relevant to your region/country. AT LEAST 4 HRS REQUIRED.
5. Basic Mediation Training Over 5-Yrs Old Basic Mediation Training More Than 5yrs Old
If your basic mediation training is more than five years old, please specify the continuing education completed over the last three years. Please note the requirement that at least 14 hours of continuing education in the last three years must be conflict resolution and/or mediation skills training. Indicate dates, trainers, institutions and duration if applicable.
6. Any disciplinary actions taken against you at any time by any professional body? Disciplinary Actions (yes/no) (Required) Disciplinary Action Details
If yes, please include date, name of professional body, type of disciplinary action and result.
7. Any ethical difficulties or criminal convictions? Ethical Difficulties (yes/no) (Required) Disciplinary Action Details
If yes, please explain.
8. Names of individuals (preferably mediators) who will complete the three reference forms.
Download the 'FMC Certification Letter of Reference' from this site at Certifications > Certification Documents. Have your references fill out the pdf and submit to
as outlined on the form.
9. Any matters that might affect negatively the general public’s perception of your ability to adhere to the Elder Mediation Code of Professional Conduct? Code of Conduct Conflicts (yes/no) (Required) Code of Conduct Conflicts Details
If yes, please explain.
10. Provide proof of liability insurance coverage (by self or employer) Proof of Liability Insurance (Required) Confidentiality
Subject to the right of the Elder Mediation Committee to release certification results for educational or research purposes, I understand and agree that only the Certifying Panel of the Elder Mediation Committee may retain certification records that identify me personally. My assessment material submitted for certification purposes will be shredded or deleted after such reasonable time as deemed appropriate by the Committee.
Accept Confidentiality Statement (Required) Statutory Declaration
I hereby certify that I will adhere to the Elder Mediation standards and professional code of conduct, and commit to continuing education for elder mediation on an annual basis.
I hereby swear or affirm that the information in this application form and its attachments is true and correct.
I hereby swear that there are no professional disciplinary actions and/or criminal convictions recorded against me.
Accept Statutory Declaration Statement (Required) Application Next Steps
Once you click 'Submit' this completed application along with supporting documents will be submitted to
Once all documentation has been received, reviewed and accepted - and you have been notified that the application has been approved - Family Mediation Canada will send you notice of certification or if you are applying for the Advanced certification, an assessor will be assigned to you who will review the next steps as outlined below.
To complete the Advanced Certification Process you are required to:
• Submit a 1 hour video of yourself in an elder mediation role play and include a written self-assessment. When you are ready for this step a guideline for the recording of the video and a role play scenario will be provided.
• Pass a three hour written exam. When you are ready to proceed to the exam a Study Guide will be provided.