Asset Protection Intake

  • MM slash DD slash YYYY
  • :
  • This is the person who needs assistance at home, is at, or going to, a skilled care nursing facility or an assisted living facility.
  • Is there a preferred name or nickname?
  • What is the client’s date of birth?
  • What is the client’s Social Security Number? 
  • What is the primary address of the client? If the client is currently residing in a skilled care nursing facility, but owns a home, then what is the address of the home owned by the client?
  • In which county does the client currently reside? For instance, if the client is currently in a skilled care nursing facility in Evansville, Indiana, then please select “Vanderburgh County, IN
  • If the client is currently admitted to a skilled care nursing facility, or resides in an assisted living facility, please provide the name of the facility.
  • What is the client’s home phone number?
  • What is the client’s cell phone number?
  • What is the client’s email address?
  • What is the client’s current marital status?
  • This field is for the spouse of the individual who needs assistance, is at, or going to, a skilled care nursing facility, or an assisted living facility. If the client is single or divorced, please disregard.
  • Is there a preferred name or nickname?
  • What is the spouse’s date of birth?
  • What is the spouse’s date of death?
  • What is the spouse’s Social Security Number? 
  • What is the spouse’s address? Leave this field blank unless different from client’s address above.
  • What is the spouse’s home phone number?
  • What is the spouse’s email address?
  • What is the spouse’s cell phone number?
  • Please list the full legal names and birthdates of all children. If any children are deceased, please list the full legal name and date of death. 
  • Please list everyone who plans on attending this meeting (include relationship to client). Each person will need to complete a basic intake form. A link to that form will be provided after this form is submitted.
  • If there is something that you’d like for us to know prior to your appointment, feel free to mention that in the space provided below.