Caregiving Planning Questionnaire

Keith C. Piscitello, CFP® CRPC®
Financial Planner
Simply Sophisticated Wealth Planning, LLC
773.867.3660 Office
847.917.0076 Mobile

www.S2Wealth.com
Keith.Piscitello@LFG.com
My Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Loved One's Name *

First Name Last Name
My relationship to loved one *
Medical Concerns
Has the caree been diagnosed with a chronic condition or serious illness?

Yes (See notes) No
Chronic Condition/Illness
Is your loved one receiving adequate care right now?

Yes No Not sure
Have you discussed any of these issues with him/her?

Yes No Not yet, but I would like to...
Are there any signs of dementia or other memory issues?

Yes (please add note) No Unsure
Memory/Dementia Concerns (if any)
Falls, wandering, unexplained car scrapes, freezer left open, stove left on, missed medications, neglected hygiene, repeated questions, etc.
How many Activities of Daily Living (ADL's) does your loved one need assistance with

Eating Bathing Continence Dressing Toileting Transferring (bed to a chair) Cognitive Impairment/Memory
Is there someone coming to the home to provide assistance?

Yes (Daily) Yes (A couple times per week) No Not yet, but I'd like to explore
Are you familiar with your family member's Medicare health insurance policies?

Yes No
Who is paying the premiums and evaluating the renewals each year?
Do you have a way to communicate with the health care professionals overseeing your loved one's care?

Yes No
Are there current life insurance or long term care policies in place that could help pay for care?

Yes No I don't know
Do you know where these policies are?

Yes No
Is there a history of longevity in your family (have other family members/grandparents lived well into their 90s)?

Yes No
What are the short-and long-term expectations for his or her current condition?
What will happen when he/she can no longer stay in the home?
Legal Concerns
Does your loved one still have the mental capacity to make decisions about his or her legal, medical, financial, and other affairs?

Yes No I'm not sure. May need help with an assessment.
Which Estate Planning documents have been completed?

Will Revocable Trust Power of Attorney for Property Medicare/Medicaid Trust Special Needs/Supplemental Needs Trust Letter of Instruction Living Will/Medical Directive Medical Power of attorney Irrevocable Life Insurance Trust
Where are these items located?
Is there an up-to-date Medical Power of Attorney (POA)?

Yes, it's been signed within the past 3 years. Yes, but it's more than 3 years old. No I don't know or can't find one.
If yes, what kind of POA is it?

Immediate and Durable Springing I don't know
Who is the Health Care Agent appointed by POA?
If there is a current POA for property, who is the appointed agent?
Is there a health care directive or "living will" and is it up to date?

Yes Yes, but it should be reviewed No I'm not sure or I don't know where it is
Have the agent and your loved one recently discussed quality of life issues regarding treatment and end-of-life decisions??

Yes, there is agreement I'm not the agent or I'm not sure There has been a discussion but it should be revisited No, I'd like help addressing this topic
Financial Matters
Can your loved one still manage their finances without assistance?

Yes No, they're receiving help I'm not sure. I have concerns.
What sources of income are available for his or her care? (Check all that apply)

Social Security Pension Investment Income Long Term Care Insurance Annuity Assistance from Family Home Equity Line or Reverse Mortgage Other
Do you know where all accounts are located?
Are you clear on your loved one's current expenses and financial needs?

Yes No
Do you have clarity on your loved one's Assets and Liabilities?

Yes No I have a rough idea
I am able to contact the following professionals that are familiar with my loved one's affairs. (Mark all that apply)

Attorney Accountant Insurance Agent Financial Advisor Realtor Care Manager
Are you familiar with how your loved one's investments are allocated?

Yes, I have complete clarity and confidence that their investments are appropriately invested and are up to date Yes, however with the pending care changes, I think a review is worth exploring. No, I'm not sure how everything fits together I'm not sure what you're asking.
Who is responsible for paying income and property taxes?
Are there current unpaid medical bills that need addressing? Who will do that?
Does anybody monitor credit, bills and checking accounts to prevent elder financial abuse/exploitation?

Yes No Not yet
Who is responsible?
I have reviewed the proper titling and beneficiary designations are up-to-date for the following (if applicable):

Life Insurance Real Estate Employer Retirement Plan (401(k)) Pension Annuity Investment Accounts Bank Accounts
Is direct deposit and automatic bill pay being utilized wherever possible?

Yes No
Personal/Residential Considerations
What living options appeal to your loved one? What is practical?
Have you investigated public assistance benefits and eligibility factors for your area?

Medication Health Care Income Assitance Food and Nutrition Housing and Utilities Tax Relief Veteran's Benefits Employment Transportation Discounts
Are there plans to enter a senior care community?
Options include active senior living, assisted living, memory care residential care skilled nursing facilities or CCRC/"Life Plan Communities".
Caregiving Needs
Who will be the primary caregiver for your loved one?
Are your job and income being impacted by your caregiving?

Yes No I'm not currently working outside the home
Is your employer familiar with your caregiving challenge?

Yes No
Are you familiar with caregiving benefits offered by your company such as those offered by the Family Medical Leave Act or any Employer Assistance Programs?

Yes No
Have you had problems with any of the following?

Managing Stress Maintaining a Healthy Social Life Asking for help Exercising regularly Proper diet (excessive weight loss or gain) Getting enough sleep Managing family communication Personal finances and/or planning
Have you considered or would you like more information on the following resources?

Geriatric Care Manager In-Home Care Aide Visiting Nurses Adult Day Care Respite Care Options Certified Caregiving Consultant SRES Certified Realtor
Is there anything else you think we should be aware of?
Keith Piscitello is a registered representative of Lincoln Financial Advisors Corp. Securities and investment advisory services offered through Lincoln Financial Advisors Corp. a broker/dealer and registered investment advisor. Insurance offered through Lincoln affiliates and other fine companies. Simply Sophisticated Wealth Planning is not an affiliate of Lincoln Financial Advisors Corp.

Lincoln Financial Advisors representatives do not provide tax or legal advice.
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Medical Concerns

Legal Concerns

Financial Matters

Personal/Residential Considerations

Caregiving Needs