CONFIDENTIAL LIFETIME PLANNING INTAKE FORM

The first part of this form is required (*) except where it is indicated that the information is optional. The second part of this form is helpful but not required – this will be indicated at the top of the page. The last part of this form is required only for potential clients who are over age 65 and/or have significant health problems – this will be indicated at the top of the page.

So long as you complete the required sections of this form, there will be no charge for the introductory meeting. However, if you choose not to complete this form, your introductory meeting will be charged at our normal hourly rates after a free 15 minute consultation. If you prefer to download this form as a fillable PDF and fill it out on your own computer or print it and fill it out by hand, please click here.


NON-SMOKING AND FRAGRANCE-FREE OFFICE: We are a non-smoking and fragrance-free office because several members of our team are sensitive to second-hand smoke, smoke residue on clothing, and chemicals found in perfumes, baby powders, bath powders, colognes, aftershaves, hairspray, and scented body lotions. All of these things can cause serious problems for people with asthma, allergies and environmental illnesses. Scented soaps and deodorants are ok, but we must ask that you refrain from wearing other scented products to our office. Also, please note that our entire building, including our parking lot, is a smoke-free zone. Thank you!


WHO SHOULD COME TO THE INITIAL CONSULATION: For Level 4 Matters, all family decision-makers should be part of the initial 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 elders. For 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 introductory meeting, but the planning session, done after the introductory meeting, must be a private meeting between attorney and the client(s).


WHAT TO BRING TO YOUR MEETING: Please bring the following documents to your introductory meeting:


Required: Long-term Care Insurance Policies and Estate Planning documents (Powers of Attorney, Trusts, Wills)


Very Helpful: Recent statements from all of your financial accounts; deeds for real estate; and life insurance policies.


Payment Method: Please be sure to bring a method of payment in the event you decide to retain us. Also please remember if you do not complete this form, your first meeting will be charged at our normal hourly rates after a free 15 minute consultation.


HOW TO PREPARE: If you haven't already, please be sure to read through our Levels of Planning before your meeting; it's on our Web site under Forms.

Name of first person completing this form

Is the Person the Primary Contact Person?*

Name of second person (if any) completing this form

Is This Person the Primary Contact Person?

Single Client or Married Couple?

All the following questions pertain to the elder or elders for whom we are planning, regardless of who is completing this form. For single clients, complete information about Client 1 only; for couples, complete information about Client 1 and Client 2.

Is This Form Being Completed for a Single Client or a Married Couple?*

Client 1 Personal Information

Home Address
Work Address
Date of Birth
Marital Status*
Date of Marriage

Client 1 Prior Spouse(s) if any

Divorced?
Date of Divorce
Deceased?
Date of Death

Client 1 Dependents

Do you have any dependents (that is, someone who depends on you, in whole or in part, for his or her support)?
Do any of your children have special needs?
If yes, does he or she receive any of the following benefits:

Client 1 - Do You Have Any of the Following Legal Documents?

Last Will and Testament
Last Will and Testament Dated
Revocable Living Trust
Revocable Living Trust Dated
Living Will
Living Will Dated
Health Care POA
Health Care POA Dated
Durable Financial POA
Durable Financial POA Dated
Other Documents?
Document Dated (if other)
Are you a citizen of the United States?
Did you ever serve in the U.S. Military?
If yes, were you active duty during wartime?

Client 1 - Number of Children

This form allows up to 7 children. If you have more than 7 children, please submit a separate sheet with their all requested information.

Client 1 - Information about First Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Second Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Third Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Fourth Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Fifth Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Sixth Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 - Information about Seventh Child

Relationship to you
Address of Child
May we talk to this child about you if needed?
May we talk to this child about you if needed?

Client 1 Additional Information

Have you ever used any other name?
Do you have prepaid funeral arrangements?
Do you have a cemetery plot?
Do you provide care to a aging parent?
Do you provide financial assistance to a child?
Do you provide financial assistance to a sibling?

Asset Protection Goals (if any):
There are two primary 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. Using the sliding scale below, please check one button to rate the relative importance of these two reasons.

Picking 1 means that it's extremely important for you to get the best possible care.

Picking 5 means that it's extremely important for you to leave inheritance.

Picking 3, the middle option, means that both things are equally important to you.

Asset Protection Goals Relative Importance

Client 2 Personal Information

Home Address - Client 2
Work Address - Client 2
Date of Birth - Client 2
Marital Status - Client 2

Client 2 Prior spouse(s)

Divorced?
Date of Divorce
Deceased?
Date of Death

Client 2 Additional Information

Have you ever used any other name?
Do you have prepaid funeral arrangements?
Do you have a cemetery plot?
Do you provide care to a aging parent?
Do you provide financial assistance to a child?
Do you provide financial assistance to a sibling?

Asset Protection Goals (if any):
There are two primary 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. Using the sliding scale below, please check one button to rate the relative importance of these two reasons.

Picking 1 means that it's extremely important for you to get the best possible care.

Picking 5 means that it's extremely important for you to leave inheritance.

Picking 3, the middle option, means that both things are equally important to you.

Asset Protection Goals Relative Importance

Client 2 - Do You Have Any of the Following Legal Documents?

Last Will and Testament
Last Will and Testament Dated
Revocable Living Trust
Revocable Living Trust Dated
Living Will
Living Will Dated
Health Care POA
Health Care POA Dated
Durable Financial POA
Durable Financial POA Dated
Other Document
Document Dated (if other)
Are you a citizen of the United States?
Client 2 - Ever serve in the U.S. Military?*
If yes, were you active duty during wartime?

Client 2 - Personal Advisors Contact Information (Helpful but Not Required)

Client 2 - Tax Accountant

May we talk to this person about you if needed?

Client 2 - Financial Advisor

May we talk to this person about you if needed?

Client 2 - Life Insurance Agent

May we talk to this person about you if needed?

Client 2 - Comprehensive Contact Information

Please identify below all of your children, including any deceased children. If they are the same as Client 1, then you can skip this section.


On a separate sheet of paper that you bring to the office, please identify any other individuals whom you may be naming either as beneficiaries or fiduciaries (i.e., executors, trustees, or agents under a medical or financial power of attorney), and any additional persons who may be involved with your planning and/or decision-making process. Please be sure to provide each person's relationship to you.

Client 2 - Number of Children

This form allows up to 7 children. If you have more than 7 children, please provide an attachment with all of the requested information.

Client 2 - Information about First Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Second Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Third Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Fourth Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Fifth Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Sixth Child

Relationship to you
Address
May we talk to this person about you if needed?

Client 2 - Information about Seventh Child

Relationship to you
Address
May we talk to this person about you if needed?

Financial Information

Do You Own Your Home or Are you Renting?
$
$
Do You Own Other Real Estate?
$
$

Client 1 Income

$
$
$
$
$
$
$
$
$
$

Client 2 Income

$
$
$
$
$
$
$
$
$
$

IRA Distributions Needed?

Do you rely on IRA Income for living expenses?

Checking Accounts

How Many Checking Accounts?
Please provide a separate attachment if you have more than 3 checking accounts
$

Savings Accounts

Please provide a separate attachment if you have more than 4 savings accounts