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Intake Form

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Confidential Client Information Form

The goal of our initial consultation is to help you design an estate plan or elder law plan that best suits your needs and wishes. This form is designed to help you organize the information we will need to maximize the benefit of our time together. Please complete this form as best you can. Do not worry if you are unable to answer every question. We request that you complete this form at least 48 hours prior to your appointment. This form will probably take you an hour or more to complete, so please don’t wait until the last minute.

The information gathered by this intake form is essential to achieve the above goals. Sections __ -__ of this form are required except where it is indicated that the information is optional.

We ask that you please complete this form at least 48 hours before your initial consultation.

Fragrance-Free Office: All of our offices are fragrance-free because several of our staff are sensitive to the chemicals found in perfumes, baby powders, bath powders, colognes, aftershaves, hair spray, and scented body lotions. These chemicals can cause
serious problems for people with asthma, allergies, and environmental illnesses. Scented soaps and deodorants are okay, but
please refrain from wearing other scented products to our office. Thank you for your understanding.

How to Prepare: If you haven’t already, please read through our Four Levels of Planning for Lifetime Protection.

Who Should Participate in the Initial Consultation: For potential Level 4 Matters, all family decision-makers should be part of the introductory consultation. This may be just the elder(s)/client(s), but often it includes the adult children or agents under power of
attorney for the elder(s). For potential Level 1, 2, or 3 Matters, the actual clients seeking to plan their estates should be present; if desired, additional family members, trusted friends, and financial advisors are welcome to attend the initial meeting, but the planning session, done after the initial meeting, must be a private meeting with the client(s).

What Documents to Provide Before Your Initial Meeting: A Client Services Team member will email you a secure document upload link once you schedule your initial consultation. Please use that link to upload as many of the following documents as possible before your initial meeting:
• Any existing estate planning documents (powers of attorney, trusts, wills, etc);
• Any existing long-term care insurance policies;
• Deeds for all real estate you own;
• Any life insurance policies or annuities you own;
• The most recent statement from each of your financial accounts.

Person(s) Completing This Form:

Please provide the information for the person(s) completing this form, which may or may not be the potential client(s).

First Person Completing Form Second Person Completing Form (if applicable)
First Name: First Name:
Last Name: Last Name:
Email: Email:
Personal Information – Clients

These questions pertain to the elder or elders for whom we are planning, regardless of who is completing this form. For single clients, complete left side only; for couples, complete both sides.

Client 1 Client 2
Prefix: Prefix:
Full Name: Full Name:
Marital Status: Marital Status:
Email: Email:
Cell Phone: Cell Phone:
Other Phone: Other Phone:
Occupation: Occupation:
Other Client Information

Do you have any dependents?

Do you have any dependents?

Do you have any children who are disabled?

Do you have any children who are disabled?

Have you ever used any other name?

Have you ever used any other name?

Citizenship, Veteran Status, Financial Support

Client 1 Client 2
Are you a U.S. Citizen? Are you a U.S. Citizen?
Are you a military veteran? Are you a military veteran?
If yes, were you active duty during wartime? If yes, were you active duty during wartime?
If yes, dates of service: If yes, dates of service:
Do you provide financial assistance to a child? Do you provide financial assistance to a child?
Do you provide financial assistance to a sibling? Do you provide financial assistance to a sibling?
Do you provide financial assistance to a parent? Do you provide financial assistance to a parent?
Do you provide care to an aging parent? Do you provide care to an aging parent?
Asset Protection Goals
Asset Protection Goals (if any): There are two reasons to protect assets; either to improve the quality of your own care when needed in the future or to preserve an inheritance for your children. Please check one box below to rate the relative importance of these two reasons.




Pick 1 if it’s extremely important to get the best possible care.
Pick 5 if it’s extremely important to you to leave inheritance.
Asset Protection Goals (if any): There are two reasons to protect assets; either to improve the quality of your own care when needed in the future or to preserve an inheritance for your children. Please check one box below to rate the relative importance of these two reasons.




Pick 1 if it’s extremely important to get the best possible care.
Pick 5 if it’s extremely important to you to leave inheritance.
Existing Estate Planning Documents
Do you have any of the following legal documents?
Last Will and Testament Last Will and Testament
Revocable Living Trust Revocable Living Trust
Living Will Living Will
Health Care POA Health Care POA
Durable Financial POA Durable Financial POA
Professional Advisors

Client 1 Client 2
Tax Accountant Tax Accountant
Name: Name:
Phone: Phone:
Email: Email:
Financial Planner Financial Planner
Name: Name:
Phone: Phone:
Email: Email:
Life Insurance Agent Life Insurance Agent
Name: Name:
Phone: Phone:
Email: Email:
Comprehensive Contact Information

Use this section to identify all of your children, including any deceased children and any children you plan to disinherit. Also identify other individuals you may be naming as beneficiaries or decision makers (i.e., trustees, executors, or agents under a power of attorney). Provide each person’s relationship to you. If you provide an email address, note that person will automatically get an invitation to sign up for our newsletter. For any info that’s the same for Client 2 as for Client 1, just write “same.”

Please enter up to eight contacts for each client.

Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Name:
Relationship: Age:
Occupation:
Cell Phone:
Email:
Street Address:
City:
State: Zip:
Other Family Members
Client 1 Client 2
Number of Living Parents: Number of Living Parents:
Number of Living Siblings: Number of Living Siblings:
Number of Deceased Siblings: Number of Deceased Siblings:



Financial Information
Type
Checking / Savings / CDs / Money Markets
Social Security
Gross Earnings from Employment
Employee Pension
Spousal Pension Continuation Benefit
Military Retirement (DFAS)
Veterans Pension (VA)
Interest / Dividends
Investment Real Estate
Distributions from IRAs
Other
Total
Real Estate

Residence Value: Mortgage Balance: Owned by:
If you have a HELOC, Amt. Borrowed: HELOC Balance Available:
Other Realty Value: Mortgage Balance: Owned by:
Financial Assets

Deposit Accounts Type of Account Owner of Account Value of Account
Total

Individual Stocks/Bonds/Treasuries Type of Account Owner of Account Value of Account
Total

Brokerage Accounts / Mutual Funds (Non-IRA) Type of Account Account Owner Beneficiaries if any Value of Account
Total
Cash Value Annuities Pre-Tax or After-Tax Account Owner Beneficiaries if any Value of Account
Total

Roth IRAs Account Owner Beneficiaries if any Value of Account
Total

Qualified Accounts
(IRAs, etc.)		 Type of Account Account Owner Beneficiaries if any Value of Account
Total
Insurance Policies (Life/Home/Auto/Umbrella)
Insurance Company Name Type of Policy Account Owner Beneficiaries if any Cash Value
Total
Existing Long-Term Care (LTC) Planning

Client 1 Client 2
Do you have Long-Term Care Insurance in place? Do you have Long-Term Care Insurance in place?
Name of Company: Name of Company:
Daily Benefit @ Facility: Daily Benefit @ Facility:
Daily Benefit @ Home: Daily Benefit @ Home:
Lifetime Benefit Amount: Lifetime Benefit Amount:
Annual Premium: Annual Premium:
Financial Decision-Makers – Helpful but Not Required

Person(s) You Wish to Name as Agent(s) under Power of Attorney, Executor, and Trustee:
This is a list of persons, in sequential order, you want to be responsible for paying your bills and managing your legal and financial affairs, both while you’re alive (if you become incapacitated), and after your death. Please try to give at least two choices, in case your first choice is unable or unwilling to act. You can indicate if you want two people as co- decision-makers, both of whom can act separately; be sure these people tend to agree so they don’t wind up in court. These are not final decisions, as all of your choices will need to be confirmed during your private Planning Session.

Client 1 Client 2
First Choice: First Choice:
Second Choice: Second Choice:
Third Choice: Third Choice:
Fourth Choice: Fourth Choice:
Medical Decision-Makers – Helpful but Not Required

Person(s) You Wish to Name as Agent(s) under Your Medical Power of Attorney:
This is a list of persons, in sequential order, you want to be responsible for making health care decisions for you if you’re unable to make such decisions for yourself. Please try to give at least two choices, in case your first choice is unable or unwilling to act. You can also indicate if you want two people who can both act independently or two people who must act jointly but be sure these people tend to agree so they don’t wind up in court.

Client 1 Client 2
First Choice: First Choice:
Second Choice: Second Choice:
Third Choice: Third Choice:
Fourth Choice: Fourth Choice:

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