Potential Client Form

POA Questionnaire
Check ALL of the boxed below to acknowledge the following:*

Completing this questionnaire does NOT create an attorney-client relationshipIf the firm accepts this case, the firm only represents the person signing the documents, even if a parent or other person provides information or pays.By submitting this questionnaire, you give the firm permission to contact you to schedule a signing appointment and collect payment (full payment required up front).
I give permission for the firm to discuss and share my documents with:
Preferred communication method(s)

PhoneEmail
Potential Client Information

This is the person who will be signing the documents
Name (as appears on your Driver's License)*

First NameMiddle NameLast NameSuffix
Other versions of your name that may appear on car titles or bank accounts
Would you like to provide instructions regarding pronouns (he/she/them/etc.) of any person whose names may appear in documents we prepare?

YesNoUnsure
Your Preferred Pronouns

He/himShe/herThey/ThemOther
Date of Birth*
Email*
example@example.com
Phone Number*
Address (can use current address or permanent address)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you currently own real estate?

YesNo
Are you currently married?

YesNo
Select a Package
The POA Package includes a DURABLE POWER OF ATTORNEY, which appoints agents to act on your behalf regarding financial decisions, and a MEDICAL POWER OF ATTORNEY, which appoints agents to act on your behalf if you cannot make medical decisions for yourself. Please select whether you want a full Will Package (additional fees will apply)

No, I just want the medical and financial powers of attorneyYes, I want a full Will Package (includes a Will, Medical Power of Attorney, Durable/Financial Power of Attorney, and documents specifying who I would want my legal guardian to be if needed, my preferences regarding life support, and who would handle my final arrangements)
Please select any additional documents you want to add to your package

"Special" or "Limited" Power of Attorney: appoints agent to act on your behalf regarding a specific property, account, or transaction (usually only prepared for a specific, immediate need) - starts at $450Supported Decision-Making Agreement: allows person with disabilities who has the mental capacity to execute legal documents to designate someone to assist them in requesting information and making decisions about education, employment, housing, benefits, etc. - starts at $250
Agents
This section will cover who you want to act on your behalf in various scenarios. Please provide the full name of each person as it appears on their driver's license.
If you are ever unable to make decisions for yourself would you want the SAME person/people to act on your behalf for medical decisions, financial decisions, and other matters?

Yes, I will be naming the same agents in the same order on all documentsNo, I want to name different people for different roles (or the same people in a different order)
List who you want to make those decisions for you in order of preference (if you want two people to have this power at the same time, select "Co-Agent", otherwise you will only have one agent at a time).*
If you are ever unable to make MEDICAL decisions, list who you want to make those decisions for you in order of preference (if you want two people to have this power at the same time, select "Co-Agent", otherwise you will only have one agent at a time).*
If you have any specific instructions or concerns related to MEDICAL matters, please describe:
Regarding the Special or Limited Power of Attorney, who do you want to act on your behalf?*
Regarding the Special or Limited Power of Attorney, please describe in detail the property, account, transaction, etc. you are authorizing your agent to handle and specify if there are any limitations (e.g. they can contact ABC bank to help me file a death benefit claim or they can sell my house located at 123 Main Street, San Antonio, Texas for no less than $150,000)
If you ever need someone to act on your behalf for FINANCIAL matters, list who you want in order of preference*
In which of the following areas do you want to name a SUPPORTER who is able to help you obtain information and make decisions?

Education/schools/job trainingEmployment/employerGovernment programs/supports/servicesMedical/mental health professionalsHousing/landlords
Your choices for a supporter in order of preference (include spouse if applicable)
Please list the name and relationship of each person you want to EXCLUDE/DISQUALIFY from acting on your behalf if you become incapacitated, if any:
Your choices for decisions regarding FINAL ARRANGEMENTS in order of preference (include spouse if applicable)
Do you have any specific requests or instructions regarding burial or cremation?
If you are unable to make your own medical decisions and are at a point where the doctors do not think you will survive without extraordinary life support measures (ventilator, feeding tube, etc.), which do you prefer?

Keep me comfortable, but remove life support measuresContinue life support even if there is little to no chance of improvementLeave decision to your family/Medical agent
If something happened to you, who would you want to receive your money and other possessions? (E.g. everything to my parents, then to my siblings)
Please provide any pronoun instructions for the individuals listed on this page.
Do you need recommendations for any other professionals?

Accountant/CPAFinancial/Investment AdvisorHome/Auto Insurance AgentBusiness Insurance AgentHome services
Other services you may want to consider (click HERE to learn more):
- Directive to Physicians: specifies preferences regarding extraordinary life support measures in extreme circumstances where recovery is not expected
- Declaration of Guardian: specifies who you would or would not want to serve as your legal guardian if you become incapacitated
- Appointment of Agent for Disposition of Remains: specifies agent(s) who will handle final arrangements (particularly important if the individual prefers cremation or next of kin do not get along)
Learn more about Ramsey Law PLLC.
How did you find the firm? E.g. Google search, Avvo.com, referral (please specify who referred you).
Enter the message as it's shown*
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POA Questionnaire

Potential Client Information

Select a Package

Agents