Intake form example

Please complete this questionnaire so we can get started drafting your estate plan.

Name * This field is required.
Phone * This field is required.
Email
Mailing Address * This field is required.
What is your marital status?
Occupation
Do you currently have a Trust?
Please list names and birthdates of your children, if any:
Do you have any deceased children? If so, please list: 1. their name(s), 2. date they died, and 3. if they had any children of their own:
Who would you like to be in charge of your finances? (If you could not manage your own) Please provide their name and relationship to you:
If the person you named above could not be in charge, do you have a second person? Please provide their name and relationship to you:
If both persons you named above are unavailable, do you have a third person you would like to name? Please provide their name and relationship to you:
If you have minor children, would you like their guardian to be someone other than those you just listed? If so, please provide their name(s) and relationship(s) to you:
Do you want your children to inherit equally?
Who would you like to inherit your estate? Please provide 1. their name(s), 2. relationship to you, and percentage you would like to give them:
Do you have a special asset that you would like handled in a particular way (e.g. House to a particular person (e.g. wedding ring to daughter, fishing equipment to neighbor,)
Please let us know any goals and objectives you would like us to know in establishing your estate plan (e.g. Making sure a child with special needs is taken care of; Avoiding taxes; Need to take care of a pet; plan for child with substance abuse issues)
Please list any real estate you own:
Please list any vehicles (cars, boats, RVs, trailers, mobile home etc.):
Do you own a business?
If you own a business please provide the name and type of business:
Who would you like to make healthcare decisions for you? Please provide their name and relationship to you:
If that person is unable to make healthcare decisions, would you like to list a second person? If so, please provide their name and relationship to you:
Upon your death, you wish to be:
Any requests for the dispositions of your remains? (e.g. Let the person you put in charge decide; Burried at _____; or Ashes scattered at _____).
Are you an organ donor?
Any wishes regarding funeral or memorial services? (e.g. Catholic Mass; Military honors; no funeral or memorial)
End of life decisions:
Is there anything else you would like us to know about your healthcare? (e.g. I purchased a burial plot already, I have my cremation services paid for, I signed up to be donated to science, etc.)