Elder Law & Medicaid Planning Intake Form

Who Are We Planning For?

Client's Full Name

Date of Birth / Age

Your Name (if different) *

Last Name *

Your relationship to client

Phone *

Email *

Current Care Situation

Facility name (if applicable)

Monthly cost (approx.)

How long at this level of care?

Marital Status

Single / Widowed / Divorced Married, spouse lives at home Married, spouse also in care

Spouse's name

Spouse's approximate monthly income

Income (Monthly — Approximate)

Social Security $

Pension $

Other income $

Taking IRA/retirement distributions Not taking distributions Not started

Assets (Approximate)

Home approx. value $

Checking / savings $

CDs / investments $

IRA / 401(k) $

Life insurance CSV $

Other assets $

Transfers & Gifting

No significant gifts in last 5 years Some gifts, unsure of amounts Significant transfers made

If transfers made, approximate amounts and when?

Existing Documents & Goals

Will Trust Financial Power of Attorney Healthcare POA / Directive

Veteran in the household No veterans

What is your main concern or goal?

Elder Law Intake Form