Date________________ Home Phone No._____________________ Business Phone No. ___________________ This form is extremely important. Your accuracy and completeness in responding will help me best represent you. Bring this information with you to the appointment. A. PERSONAL DATA
Full Name___________________________________________________________________________________ (print name as shown on your checks) Street Address ________________________________________________________________________________ City __________________________________________________________ State ___________ Zip ____________ Birth Date _____________________________________ Social Security No. ____________________________ U.S. Citizen? Yes ___ No ___ Veteran? Yes ___ No ___ If widowed, please list date of death of spouse ______________________________________________________ Was your former spouse a Veteran? Yes ___ No ___ B. MEDICAL DATA
1. HEALTH
Diagnosis
___________________________________________________________________________________
Prognosis
___________________________________________________________________________
Course of Treatment
___________________________________________________________________________
If you are already in a nursing home, please indicate the name of the nursing home and the
date first entered
____________________________________________________________________________________
2. PHYSICIAN
Full Name of Primary Physician
_________________________________________________________________
Street
Address________________________________________________________________________________
City_________________________________________________________ State__________
Zip______________
3. STATE PHARMACEUTICAL PLAN
Are you currently on PAAD (Pharmaceutical Assistance to the Aged and Disabled Program) or
any other state pharmaceutical plan? Yes ___ No ___
C. MONTHLY INCOME
Social Security Benefits $___________________
(include $43.80 Medicare Part B
Deduction, if applicable)
Retirement Benefits (Gross) $___________________
Veterans Disability Income $___________________
Annuity Income $___________________
Rental Income $___________________
TOTAL MONTHLY INCOME $___________________
If there is a pension, please list the gross pension amount, including any monies taken out
for federal income taxes, health insurance, or any other reason.
Could this pension amount increase in the future? Yes ___ No ___
Do not include interest and dividend income on this form.
D. MONTHLY COST OF NURSING HOME
Monthly Nursing Home Cost $___________________
Monthly Prescription Cost $___________________
Monthly Incontinent Cost $___________________
Monthly Other Cost $___________________
Total Monthly Cost $___________________
The nursing home is paid through
_________________________________________________(month/year).
E. ASSETS/LIABILITIES
Please insert the value of each asset/liability in the appropriate space.
ASSET/LIABILITY
ASSET TOTAL
LIA-BIL-I-TY TOTAL
PERSONAL EFFECTS
CHECKING ACCOUNT
SAVINGS ACCOUNT
MONEY MARKET ACCOUNT
CERTIFICATES OF DEPOSIT
RESIDENCE (ASSESSED VAL-UE)
BLOCK#___________ LOT#___________
(Ob-tain from Tax Bill)
OTHER REAL ESTATE
AUTOMOBILE(S)
MUTUAL FUNDS
STOCKS
BONDS
ANNUITIES
CASH VALUE - LIFE INSURANCE
IRA
NURSING HOME DEPOSIT
OTHER
OTHER
TOTAL
What did you pay for your current home including any improvements?
$_____________________________
Address of any real property other than personal residence:
(1)Street ________________________________________City
______________State________Zip___________
Tax Block # , Lot # (Can be obtained
from Tax Bill)
What did you pay for this property including any improvements?
$_____________________________________
(2)Street ________________________________________City
______________State________Zip___________
Tax Block # , Lot # (Can be obtained
from Tax Bill)
What did you pay for this property including any improvements?
$_____________________________________
Name of Homeowner's Insurance
Company________________________________________________________
Street
Address________________________________________________________________________________
City_________________________________________________________ State__________
Zip______________
Phone No.___________________________________ Policy No._________________________________
F. GIFTS
Please list gifts made in excess of $3,000 in any one month, to an individual or group of individuals, within the past 36 months: Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ Recipient___________________________________ Date ______________ Amount ____________ G. LIFE INSURANCE
COMPANY NAME
(include address and policy #)
TYPE
DEATH
BENEFIT
VALUE
FACE VALUE
CASH VALUE
INSURED
OWNER
BENEFICIARY
(Include the cash value of the life insurance on the life insurance line in Section E)
It is very important to know the cash value and the death benefit of your life insurance
policy. To obtain the cash value of the policy, please call your insurance agent, or call
the insurance company directly.
H. CHILDREN (if applicable)
| CHILD'S NAME | ADDRESS (WITH ZIP CODE ) |
TELEPHONE NUMBER | DATE OF BIRTH | SOCIAL SECURI-TY NUMBER |
484ms
Are all of your children in good health? Yes ___ No ___
Are any of your children blind? Yes ___ No ___
Are any of your children disabled? Yes ___ No ___
Are any of your children receiving SSI or other form
of government entitlement? Yes ___ No ___
Do any of your family members have any problems with:
Aids? Yes ___ No ___
Drug Addiction? Yes ___ No ___
Alcoholism? Yes ___ No ___
Spendthrift? Yes ___ No ___
Do any of your children live with you in your home? Yes ___ No ___
If yes, name of
child________________________________________________________________________
Does a sibling live in your home with you? Yes ___ No ___
If yes, name of
sibling_______________________________________________________________________
I. MISCELLANEOUS Do you have any other legal issues which I should be aware of: Yes ___ No ___
If yes, please explain
__________________________________________________________________________
___________________________________________________________________________________________
J. REFERRAL By Whom Were You Referred To This Office?
Name
_______________________________________________________________________________________
Street
Address________________________________________________________________________________
City_________________________________________________________ State__________
Zip______________
K. CERTIFICATION
The undersigned hereby represents to Roy W. Wilkes, Esquire The Elder & Disability
Law Firm., and each of its attorneys that the
information contained in this intake form is accurate and complete, and that the
undersigned understands
that the law firm and its individual lawyers will rely on this information. I understand
that if the information
contained herein is inaccurate or incomplete, the recommendations made by the law firm may
not be
appropriate.
Signature of Client or Client Representative:
____________________________________________________