Long-Term Care Questionnaire

Long-Term Care Questionnaire

Bertsch & Boze Elder Law, PC
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Is the above client married?

YesNo
If yes, please provide information for Spouse Below:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Does the client have children?

YesNo
if yes, Please provide info below:
Number of Children
Are any minors or persons with disabilities?

YesNo
Who Should be Our Primary Point of Contact?
Contact Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Alternate Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Client
Does the Client have an existing Will, Trust, Powers of Attorney or other Estate Planning documents? If so, it is VERY IMPORTANT that you bring a copy of them to the meeting.

What we need to know for the Client:
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross, if possible)
US Dollars
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross, if possible)
US Dollars
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross if possible)
US Dollars
What we need to know for the Spouse.
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross if possible)
US Dollars
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross if possible)
US Dollars
Income Social Security, Pension, VA/SSI (Include Type of Income)
Monthly Amount (Gross if possible)
US Dollars
Real Estate:
Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Approximate Value
US Dollars
Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Approximate Value
US Dollars
Real Estate Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Approximate Value
US Dollars
Finincial Accounts:
Mineral Rights:
Vehicles:
Life Insurance Policies:
Burial/Furneral Policies
Did the Client make any 'gifts' over $200 in the last 5 years? A "gift' includes any transaction in which the Client received less than fair market value back in return for the 'gift' given. This also includes any sale of assets to the family members or friends for less than full market value

YESNO
IF YES, please complete fields below.
Did the Client or Spouse sell any home, property, vehicle, recreational vehicle, or any other major asset in the last 5 years?

YesNo
IF YES, Please complete
Should be Empty: