EMERGENCY PLANNING REQUEST FORM

1
Who is completing this form?* This field is required.This helps us know whether we should contact you or the person who needs the documents directly.
I am the person who needs the documents.
I am helping a family member, partner, or friend.
2
What is your full name?* This field is required.Please enter the name of the person completing this form.
First Name
Last Name
3
What is the best phone number for immediate follow-up?* This field is required.Please provide a number where we can reach you promptly about this request.
Please enter a valid phone number.
4
What is the best email address?* This field is required.We will use this email to send follow-up information and documents if the Firm accepts the matter.
example@example.com
5
What is the full legal name of the person who needs the documents?* This field is required.Enter the name exactly as it should appear on the legal documents.
First Name
Middle Name
Last Name
6
What is your relationship to the person who needs the documents?* This field is required.For example: spouse, partner, adult child, sibling, parent, friend, or caregiver.
7
Is the person who needs the documents currently hospitalized?* This field is required.Your answer will help us determine the appropriate next steps and timing.
No — preparing for surgery, treatment, or possible hospitalization.
Yes — currently admitted to a hospital.
Recently discharged and needs the documents promptly.
8
What is prompting this request?* This field is required.Select the option that best describes why the documents are needed now.
Scheduled surgery
Upcoming medical procedure
Current hospitalization
Recent hospitalization or discharge
New diagnosis
Upcoming travel
General concern about incapacity
Other
9
Is there a scheduled surgery, procedure, admission, or other important date?Leave this blank if no date has been scheduled.
Date
Day
Month
Year
10
Where would you prefer to sign the documents?* This field is required.Hospital-room appointments are available only for patients who are currently admitted and able to understand and voluntarily sign the documents.
At the David Flores Law Firm office near the Texas Medical Center
In the patient’s hospital room
Another location to be discussed
I am not sure yet
11
How soon are the documents needed?* This field is required.Requested timing is subject to attorney availability and completion of the intake, agreement, and payment.
As soon as possible today
Within 24 hours
Within 2–3 days
Within one week
More than one week from now
12
Is the person currently awake and able to communicate directly?* This field is required.The attorney must be able to speak directly with the person who needs the documents before accepting the matter.
Yes
Sometimes
No
I am not sure
13
Is the person currently able to understand information and make personal decisions?* This field is required.The attorney will make an independent determination before accepting the matter or preparing documents.
Yes
Sometimes
No
I am not sure
14
Has the person recently received sedation, strong pain medication, or other medication that may affect alertness?* This field is required.This does not automatically prevent representation, but the attorney must confirm that the person can understand and voluntarily sign the documents.
No
Yes
I am not sure
15
At which hospital is the person currently admitted?* This field is required.Please include the hospital name and campus location, if known.
16
What is the patient’s building, floor, and room number?Enter the information currently available. Please notify the Firm if the patient is transferred.
17
Is discharge or transfer expected soon?* This field is required.This helps the Firm evaluate timing and whether an office signing may be more practical after discharge.
Within 24 hours
Within 2–3 days
Later or unknown
I am not sure
18
Can the attorney speak directly with the person who needs the documents?* This field is required.Direct communication with the proposed client is required before the Firm can accept the matter.
Yes, by phone
Yes, by video call
Yes, in person
Not currently
I am not sure
19
Is there any disagreement among family members or others about who should make decisions or receive authority?* This field is required.A disagreement may affect whether the Emergency Planning Package is appropriate for the situation.
No
Yes
I am not sure
20
Does the person already have any powers of attorney, healthcare directives, or similar documents?* This field is required.If documents already exist, the attorney may need to know whether they are current and why new documents are being requested.
No
Yes
I am not sure
21
Please briefly describe the existing documents and why new documents may be needed* This field is required.
Huge
Large
Normal
Small
Ok
Ok
22
What state does the person currently live in?* This field is required.This service is generally intended for Texas residents and Texas legal documents.
Texas
Texas
Another U.S. state
Outside the United States
23
Which state?
24
Which country?
25
Please briefly explain the situation and any timing concerns.* This field is required.Do not include Social Security numbers, financial account numbers, detailed medical records, or other highly sensitive information.
Huge
Large
Normal
Small
Ok
Ok
26
How did you hear about David Flores Law Firm?* This field is required.This helps the Firm understand how people are finding this service.
Please Select
Google search
Google Business Profile
Facebook
LinkedIn
Alignable
Referred by an attorney
Referred by a financial professional
Referred by a healthcare or social-service professional
Referred by a former client
Friend or family member
Other
27
Who referred you?
28
Please confirm the following* This field is required.I understand that submitting this form does not create an attorney-client relationship. I understand that the Firm must speak directly with the person who needs the documents before accepting the matter. I understand that the person must be able to understand the documents, communicate personal decisions, and sign voluntarily. I understand that the Firm cannot guarantee same-day, after-hours, weekend, or hospital-room availability. I understand that the Emergency Planning Package is not a complete estate plan. I authorize David Flores Law Firm to contact me by telephone, text message, and email about this request.
I have read and agree to the statements above.
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