Elder Financial Exploitation Study Eligibility/Participation Form

If you meet these criteria, please fill out the following information so we may be in contact with you. Then complete the consent form, below this form on this webpage. Once we receive your signed consent form, we will email you a private, personal link to the survey or we can conduct the survey with you over the phone if you prefer. If you meet the criteria and your survey is completed, we will send you a $20 money order to compensate you for your time. One of our researchers or our research assistant will then contact you to schedule an interview to provide you an opportunity to share your story and to explain further your survey responses. We will again compensate you for your time.

If you are interested in participating in our survey, indicate (with a check) whether you meet each these eligibility criteria:

US resident: *
Yes No
English speaking: *
Yes No
18 years old or older: *
Yes No
Have one or more family member(s) 60 years old or older who have appointed a family member as their power of attorney agent to make decisions when they cannot.: *
Yes No
Type of experience with a family member power of attorney for an older relative: *
My family has had at least alleged or suspected an older relative is being exploited financially by a family member. My family has had no problems with a relative financially exploitin an older relative.
First Name: *
Last Name: *
Complete Mailing Address (street or P.O. Box, city, state, & zip code): *
Phone Number: *
Email: *
Are there other family members who would be willing to participate?: *
Yes No Maybe