Elder Law Information Center

Elder Law Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

City

State

Zip

What is your marital status?
Choose OneSingleMarriedDivorcedSeparatedWidowed

What is your age?
Choose One20-3031-4041-5051-6061-6566 or older

Do you own your home?
Yes  No 

Does anybody else reside with you at your home?
Yes  No 

Have you executed a will, trust, power of attorney, living will, health care proxy or any other estate planning document?
Yes  No 

If yes, please indicate the type of document.

Are you currently receiving assistance from Medicare, Medicaid, Social Security, or any other government program?
Yes  No 

If yes, please specify the nature of your assistance.

Do you have a long-term care insurance policy?
Yes  No 

If yes, please provide the name of your insurance company and amount of coverage, if known.

Do you have any chronic physical or mental conditions for which you have sought medical attention?
Yes  No 

If yes, please specify each condition.

Do you have a family history of physical or mental conditions requiring prolonged medical attention?
Yes  No 

If yes, please specify each condition.

Have other attorneys worked on this matter?
Yes  No 

If yes, provide names, addresses, and a brief description of their involvement:

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