Minors & Individuals that Lacks Capacity

1

What is your name?

First Name

Last Name

2

I am a...* This field is required.

Person with a Disability or Injury

Attorney

Settlement Consultant

Friend or Family Member

3

Is anyone in the household a minor or an adult that lacks capacity with a need to utilize means-tested benefits (i.e. Medicaid* and/or Supplemental Security Income)?Please note, some states refer to their Medicaid program by a different name such as: Medi-Cal in CA, AHCCS in AZ, and MassHealth in MA.

Yes

No

I'm Not Sure

4

Is your client, or loved one, a minor that needs access to funds prior to age 18, but does not need to currently utilize means-tested benefits (i.e. Medicaid and/or Supplemental Security Income)?

Yes

No

I'm Not Sure

5

Is your client, or loved one, an adult without capacity that needs protection from misappropriation and/or wants the option to become eligible for means-tested benefits in the future (i.e. Medicaid and Supplemental Security Income)?

YESNO

6

What is Your Preferred Contact Method?* This field is required.

Phone

Email

7

What is Your Phone Number?

Area Code

Phone Number

8

What is Your Email Address?

example@example.com