"Do Not Represent Me" Form

The National Placement & Referral Alliance's "Do Not Represent Me" form is a tool for clients (or their families) to formally indicate that they do not wish to be represented by a particular senior living placement service, agency, or agent.

This form could be relevant in situations where a family has contacted multiple agencies for assistance and wants to clarify which agency they have chosen to work with. It might also be used if a family decides to discontinue services with an agency.

The form serves to protect the rights of the client by ensuring that their preferences regarding representation are respected and to prevent any misunderstandings about who is authorized to act on their behalf in the sensitive process of finding senior living arrangements.

Please click the 'Start' button below to take this "Do Not Represent Me" form. After you complete the form, you will receive an email and a pdf document with your submission information.

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