Elder Law

Initial Confidential Questionnaire

 

Note:  This questionnaire is designed to be used by a paralegal while conducting an initial client interview.  The paralegal may encounter some resistance during the initial interview when the client is asked information regarding personal and financial data.  The paralegal must convey to the client the absolute necessity of providing the information in order to help the elder lawyer counsel the client about the legal issues that are now confronting the client.  The client must be informed that the information provided to the elder law office is strictly confidential and will be used only for the benefit of the client.

 

Date of Interview_________________       File No._________________

Source of Referral______________________________

 

General Information

 

Full Name:  _____________________________________________________________

                                  First                               Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

Date of Birth_____________________           Place of Birth________________________

Social Security #______________________________

Reason for Appointment____________________________________________________

 

Consultation Regarding____________________________________________________

 

Relationship_____________________________________________________________

 

Full Name:  _____________________________________________________________

                                  First                               Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

Owns (   )                                 Rents(   )          How Many Years_____________________

Date of Birth_____________________           Place of Birth________________________

U.S. Citizen      (   )Yes    (   ) No    (   ) Other____________________________________

Social Security #______________________________

Marital Status:   (   ) Married                 (   ) Widow(er) (   ) Never Married

Prior Marriages  (   ) No                       (   ) Yes                        How Many_______

How were they termainated?                 (   ) Divorce                  (   ) Annulment  (   ) Death

Prenuptial Agreement    (   )Yes             (   ) No

            (A) Date and Place of Final Dissolution             (   ) Divorce

                                                                                                (   ) Annulment Decree________

(B)    Name of Prior Spouse ___________________________________

(   ) Deceased   (   ) Living

Religion_________________________________________

Primary Care Giver   (   ) Spouse      (   ) Child          (   ) Aide

 

Immediate Family Members

 

Spouse

Name of Spouse ____________________________________________________________

                                                First                             Middle                         Last

 

Children

Name_______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

 

 

Name_______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

 

Stepchildren

Name______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

Name_______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

Adopted Children

Name_______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

 

Name_______________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

 

Grandchildren

 

Name_____________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

 

Name________________________________________________________________________

                                    First                             Middle                         Last

 

________________________________________________________________________

Number and Street

 

________________________________________________________________________

City                                          County                         State                Zip Code

 

________________________________________________________________________

            Home Phone                            Cell Phone                                Fax

 

(   ) Deceased   Date:_____________              (   ) Living        

DOB: _________________                Age:___________

SSN:________________________    Marital Status:___________________________

Name of Spouse: _____________________________________       Occupation:______________

 

Other Family Members Not Listed Above

 

Name_________________________________________________ Relationship_____________

                        First                 Middle                   Last                                   

______________________________________________________________________________

            Number and Street

______________________________________________________________________________

 City                             County                                     State                Zip Code

Family Background

General Information Regarding Family Relationships and Potential Conflicts

 

______________________________________________________________________________

 

______________________________________________________________________________

Medical Information

Current Medical Status:__________________________________________________________

 

Prognosis:_____________________________________________________________________

 

Name of Treating Physician(s)_____________________________________________________

 

Address:______________________________________________________________________

 

Telephone#:__________________________              Fax#:_______________________________

 

 

Name of Treating Physician(s)_____________________________________________________

 

Address:______________________________________________________________________

 

Telephone#:__________________________              Fax#:_______________________________

 

 

Name of Social Worker__________________________________________________________

 

Address:______________________________________________________________________

 

Telephone#:__________________________              Fax#:_______________________________

 

Currently At:     (    ) Home

                        (    ) Hospital                (Name)_________________________________________

 

Lives With:       (    ) Spouse

                        (    ) Child

                        (    ) Aide – How many hours a week____________________________________

                        (    ) Independent Living Facility (Name)_________________________________

                        (    ) Assisted Living Facility (Name)____________________________________

                        (    ) Skilled Nursing Facility (Name)____________________________________

                        (    ) Lifecare Community (Name) ______________________________________

                        (    ) Patient Review Screening Required (PRI)

                        (    ) Nursing Home Placement Required

Recent Hospital Admission___________________________

Date of Discharge________________________         To:______________________________

 

Entitlement Benefits

Is Incapacitated Person Receiving:

Medicare          (    ) Yes           (    ) No Medicare #_______________________

(    ) Nursing Home Coverage 100 days

Medicaid          (    ) Yes           (    ) No  Medicaid # ______________________

Medicaid Liens Filed    (    ) Yes           (    ) No

Medical Insurance        (    ) Yes           (    ) No

Company____________________________________________  Policy # __________________

Long-Term Care Insurance:      (    ) Yes           (    ) No

Company____________________________________________  Policy # __________________

 

Medical Condition

 

(    ) Alzheimers Disease

            Stages: (    )Early                      (    ) Wanderer

                        (    ) Middle                  (    ) Aggressive

                        (    ) Late

(    ) Alzheimers Related Dementia

(    ) Arthritis

(    ) Blind

(    ) Confined to bed at home

(    ) Diabetic                            (    ) Amputee

(    ) Emphysema

(    ) Falls regularly       

(    ) Feeding tube

(    ) Nasal

(    ) Parenteral (stomach)

(    ) Fracture

(    ) Hip/Pelvis              (    ) Right/Left Limb

(    ) Frail

(    ) Heart disease

(    ) Heart attack

(    ) Bypass surgery

(    ) Valve replacement

(    ) Hypertension

(    ) Incontinent

(    ) Multiple Sclerosis

(    ) Organic brain syndrome

(    ) Parkinson’s Disease

(    ) Senile dementia

(    ) Stroke

(    ) Comatose                                                 (    ) Semi-Comatose

(    ) Ventilator Dependent

(    ) Paralysis                                                   (    ) Left Side               (    ) Right Side

(    ) Aphasic

(    ) Dysphasia (Inability to swallow)

(    ) Requires physical therapy

(    ) Requires speech therapy

 

Needs Assistance With Activities of Daily Living:

 

(   ) Walking      (   ) Toileting     (   ) Dressing

 

(   ) Baffling      (   ) Feeding      (   ) Transferring from bed to chair

 

 

Mental Status:

 

(   ) Confused

(   ) Disoriented

(   ) Short-term memory loss

(   ) Arrange for medical/psychiatric evaluation

(   ) Able to execute documents               (   )Yes            (   ) No

                                                                                    (   )With x

 

Medical Condition of Spouse:

(   )Good

(   )Fair

(   )Poor

(   )Other

 

Mental Status:

(   ) Confused

(   ) Disoriented

(   ) Short-term memory loss

(   ) Arrange for medical/psychiatric evaluation

(   ) Able to execute documents   (   ) Yes          (   )No

                                                                                    (   ) With x

 

HAVE THE FOLLOWING ADVANCE DIRECTIVES BEEN EXECUTED?

Will                                                                                            (   )Yes (   ) No
Durable power of attorney                                                          (   )Yes (   ) No
Living will                                                                                  (   )Yes (   ) No
Health care proxy with advance declaration                                 (   )Yes (   ) No
Advance directive for appointment of guardian                             (   )Yes (   ) No
Do not resuscitate (DNR) order                                                  (   )Yes (   ) No

 

Trusts:

Has the client created any trusts?                                               (    ) Yes  (    ) No

Living trust                                                                                 (    )Yes   (    ) No      

Irrevocable trusts                                                                        (    ) Yes  (    ) No

Testamentary trusts                                                                    (    ) Yes  (    ) No

Copies of trusts available                                                             (    ) Yes  (    ) No

Life insurance trust                                                                     (    ) Yes  (    ) No

Special needs trust                                                                      (    ) Yes  (    ) No

If not available, they must be obtained.

 

Tax Returns:

Are income tax returns filed: (    ) Yes  (    ) No                          Date of last Filing:  _____________

Are copies of last three years available:                                       (    ) Yes  (    ) No

Have gift tax returns been filed?                                                  (    ) Yes  (    ) No

Are copies available?                                                                  (    ) Yes  (    ) No

 

Safe Deposit Box:

Does elderly person rent a safe deposit box?                                (    ) Yes  (    ) No

Location __________________________

Title on safe deposit box ___________________________________________

FINANCIAL INFORMATION

Husband: Benefits

Social Security, Vet Adm, Disability, Workers’ Compensation, Employment, Retirement, Death.

 

 Type

          Payor

  Amount       per Month

Electronic Dep.     (  )Yes or (   )No

              Where

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wife: Benefits

Social Security, Vet Adm, Disability, Workers’ Compensation, Employment, Retirement, Death.

 

 Type

          Payor

  Amount       per Month

Electronic Dep.     (  )Yes or (   )No

              Where

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gifts

 

    Date

      Amount     (type of property)

             To Whom                   

Gift Tax Returns Filed

         (Attach copies)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 Cash

 

            Bank

Name  &  Address

    Type of Account

Savings, IRA, Checking, CDs maturity dates

       Title of Account

 Current                              Balance                                              

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stocks, Bonds, Mutual Funds, Notes Receivable, Mortgages Receivable, Government Issued Bonds, Securities

 

             Name of Security

                Ownership

Number of

    Shares

  Current

     Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Real Estate

 

Type of Property:

Residence, Commercial, Vacant Land, 2nd Home

  Names on Title

 Current Fair

 Market Value

     Location

Mortgages

Bank/Private

Current Balance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Life Estates

 

Date Life Estate Created

       Life Tenant

Remainderman

         Type of Real Estate

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal Property

 

List all Items of Substantial Value

(Cars, Jewelry, Artwork, Boats, etc)

     Ownership

   Fair Market

        Value

     Covered by

       Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Future Inheritances:

List all expected inheritances, trust interest etc..

 

             From Whom

               To Whom

                Amount

 

 

 

 

 

 

 

 

 

 

 

 

Business Interest of Any Nature:

 

          Type of Business

Description of Ownership/Interest

      Value of Interest

 

 

 

 

 

 

 

 

 

 

 

 

 

Life Insurance

 

     Name of

Insurance Co.

   Policy

   Owner

   Insured

Face Value       Loans

Beneficiary Primary & Contingent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pensions, IRA, Accounts Annuities

 

      Type

            Payor

 Amount per

     Month

       Custodian

Current Value

   Beneficiary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Liabilities

 

               Debtor

    Description

 Amount Due

       Creditor

   Secured

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Miscellaneous/Information

 

 

 

 

 

 

 

 

 

 

CheckList

To Do:

 

1.         Obtain Medical Report                                                         (    ) ____________________

2.         Obtain Psychiatric Evaluation                                               (    ) ____________________

3.         Obtain Real Estate Appraisal                                               (    ) ____________________

4.         Obtain Current Bank, Financial Statements, Info.  (    ) ____________________

5.         Obtain Copies of all Tax Returns-Income & Gift                (    ) ____________________

6.         Obtain Copies of all Deeds to all Real Estate                     (    ) ____________________

7.         Obtain PRI and Screen                                                          (    ) ____________________

8.         Interview Next of Kin                                                            (    ) ____________________

9.         Prepare Last Will & Testament                                            (    ) ____________________

10.       Prepare Durable Power of Attorney                         (    ) ____________________

11.       Prepare Health Care Proxy                                                   (    ) ____________________

12.       Prepare Living Will                                                                (    ) ____________________

13.              Prepare Advance Directive for the Appointment of a

Guardian                                                                                 (    ) ____________________

14.       Medicaid Application                                                 (    ) ____________________

15.       Nursing Home Placement                                                      (    ) ____________________

16.       Home Care Assistance                                                          (    ) ____________________

17.       Adult Home Placement                                                          (    ) ____________________

18.       Assisted Living Facility Placement                                       (    ) ____________________

19.       Transfer Residence                                                               (    ) ____________________

20.       Create Life Estate                                                                 (    ) ____________________

 

 

Name of paralegal who conducted intake___________________________________________

 

Time spent by paralegal ________________________________________________________