About You

Preferred Contact Method

Select an option Email Phone No Preference

Gender

Male

Female

Marital Status

Single

Married

Spouse's Full Name

Separated

Spouse's Full Name

Divorced

Former Spouse's Full Name

Widowed

Former Spouse's Full Name

Do you have children?

Yes

Please List the Names & Ages of Children Below:

No

Who do you want as your beneficiaries?

Legal Assistance Needed

Which type of legal assistance do you need?

Medicaid Planning (Qualifying for Medicaid, protecting assets, long-term care)Estate Planning (Wills, Trusts, Powers of Attorney, asset protection)Guardianship & Conservatorship (Legal guardianship for a loved one)Probate & Trust Administration (Handling a loved one’s estate, trustee support)Special Needs Planning (Trusts & Protection for Disabled Loved Ones)Elder Law (End-of-Life Planning, Healthcare Decisions)Other

What is your main concern or goal for seeking legal help?

Do you already have any of the following legal documents? (Check all that apply)

WillTrustPower of Attorney (Financial & Healthcare)Durable Power of Attorney (Financial & Healthcare)Advance Healthcare Directive / Living WillMedicaid PlanNone of the above

Do you have an urgent deadline for this matter?

Yes

Please explain below:

No

What is your ideal timeline for completing this legal matter?

Select an option Immediately (Next 1-2 Weeks) Within 1 Month Within 3 Months No Rush / Just Gathering Information

Any additional information you would like to share?

Financial Snapshot (For Medicaid & Estate Planning Clients)

Do you own a home?

Yes

If Yes, Estimated Value: $_________ Mortgage Balance: $_________

No

Do you have a retirement account (401k, IRA, pension)?

Yes

If Yes, Approximate Total Value: $_________

No

Do you have any life insurance policies?

Yes

If Yes, Policy Number and Value: $_________

No

Do you have any outstanding debts (medical bills, loans, credit cards)?

Yes

If Yes, Approximate Amount: $_________

No

How Did You Hear About Us?

How were you referred to our law firm?

Friend or family member

Input the person's full name:

Another attorney

Input the attorney's full name:

Online search or lawyer directory website

Input the name of the website:

For example, "Avvo", "Facebook", or "LawFirmName.com"

Billboard, bus stop, phone book, newspaper, or other physical advertisement

Where was the ad located?

Radio or TV advertisement

What radio or TV station?

Bar Association

Which Bar Association?

Other

Please explain how you found us:

Payment & Legal Fees

If our law firm ends up representing you in this matter, will you be the person who pays the legal fees?

Yes

How do you plan to pay?

Please indicate the source of funds or otherwise confirm that you have the ability to pay your legal fees.

No

Input the full name of the person who will pay the legal fees: Input his/her phone number: Input his/her email address:

Terms & Privacy Policy (Required)

Please acknowledge that you have read and hereby accept the above privacy policy regarding use of my personal information by typing your full legal name below

THANK YOU