Client Intake Form: Elder Law

Full Legal Name *

Are you known by any other names? *

Date of Birth: *

Gender *
MaleFemale

Address *

City *

How long have you lived there? *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

City of Birth

Zip Code *

Home Phone

Cell Phone *

E-Mail Address *

Work Phone

Checkboxes
YesNo

Social Security Number (Last 4 Digits)

Do you have a valid driving license? *
YesNo

Are you a United States citizen? *
YesNo

Any significant health concerns?

Have you or your spouse been married previously? (if so, please detail when, where and how the marriage ended)

Name *

Gender
SelectMaleFemale

H/W/J

DOB

Deceased children, if any

Are your children and other beneficiaries in good health?

Do you have any concerns regarding children/beneficiary’s money management skills?

Do any of your children have special needs?

Are you a caretaker or guardian for anyone else?

Do you have any Long-term Care Insurance?

Do you have a Prepaid funeral?

Do you have any Estate Planning documents already completed? If so, what do you already have?

Retirement Plans (including IRA’S) Husband / Wife:Total Value

Type of Plan/ Owner

Company

Beneficiary

Value/Income

Company

Type

Insured

Owner

Beneficiaries-1st:

2nd:

Cash Value:

Death Benefits:

Business Interests and Partnerships::Total Value

List details and ownership

General Description or Address:

Owner:

Market Value:

Mortgage Benefits:

Personal Effects (Total Value):

Type of Property:Automobiles

Owner:

Market Value:

Type of Property:Family Heirlooms

Owner:

Market Value:

What are your current concerns?

Please upload your picture (a selfie is OK). This will allow your attorney to find you more easily in crowded courthouses.