EP Intake - Law Office of Glenn A. Deig

What is the date of your appointment?

What time is your appointment?

:

Full Legal Name of New Client*

Preferred Name of New Client

Is there a preferred name or nickname?

Date of Birth

What is the client’s date of birth?

Address

Street Address Address Line 2 City State ZIP Code

Home Phone Number (if applicable)

What is the client’s home phone number?

Cell Phone Number (if applicable)

What is the client’s cell phone number?

Email Address (if applicable)

What is the client’s email address?

Employer (if applicable)

Employer Phone Number (if applicable)

Preferred Method(s) of Contact (check all that apply)

Cell (text)
Cell (voice)
Email
Home Phone
Work Phone
Other

Marital Status

What is the client’s current marital status?

If client is married or widowed, what is the full legal name of the spouse?

Preferred Name of Spouse

Is there a preferred name or nickname?

Spouse’s Date of Birth

What is the spouse’s date of birth?

Spouse’s Date of Death (if applicable)

What is the spouse’s date of death?

Spouse’s Address (if different from client’s address above)

What is the spouse’s address? Leave this field blank unless different from client’s address above.

Street Address Address Line 2 City State ZIP Code

Spouse’s Home Phone Number (if applicable)

What is the spouse’s home phone number?

Spouse’s Email Address (if applicable)

What is the spouse’s email address?

Spouse’s Cell Phone Number (if applicable)

What is the spouse’s cell phone number?

Employer (if applicable)

Employer Phone Number (if applicable)

Preferred Method(s) of Contact (check all that apply)

Cell (text)
Cell (voice)
Email
Home Phone
Work Phone
Other

Full Legal Names and Birthdates of Children

Please list full legal names of all children. Please include each child’s date of birth followed by a mention of whether the child is from this marriage; if not from this marriage, please mention which is the parent. For instance: John A. Smith 1–1‑1975 (Both) Susan A. Smith 2–5‑1972 (Betty’s daughter)

Full Legal Names and Dates of Death of Deceased Children

Please list the full legal names and dates of death of any deceased children.

Who will be attending this meeting?

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.

Do any of the children, grandchildren, or heirs have any special needs or disabilities? if so, you may explain here:

Have you previously executed any of the following documents: (check all that apply)

Last Will & Testament
Power of Attorney
Healthcare Representative
Living Will
Trust

Is this client a previous client or has this client had a previous consultation with Glenn A. Deig?

Yes
No
Not sure

How did you hear about Glenn A. Deig, Attorney at Law?

Anything else?

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.

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Estate Planning Intake