Nursing Home - Asset Protection Intakes - Law Office of Glenn A. Deig

What is the date of your appointment?
MM slash DD slash YYYY
What time is your appointment?

: Hours

Minutes

AM/PM
Full Legal Name of New Client*
This is the person who needs assistance at home, is at, or going to, a skilled care nursing facility or an assisted living facility.
Preferred Name of New Client
Is there a preferred name or nickname?
Date of Birth
What is the client’s date of birth?
Month
Day
Year
Social Security Number (optional)
What is the client’s Social Security Number?
Address
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?

Street Address Address Line 2 City State ZIP Code
County of Residency
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”
Current Nursing Facility or Assisted Living Facility (if any)
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.
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?
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?
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.
Preferred Name of Spouse
Is there a preferred name or nickname?
Spouse’s Date of Birth
What is the spouse’s date of birth?
Month
Day
Year
Spouse’s Date of Death (if applicable)
What is the spouse’s date of death?
Month
Day
Year
Spouse’s Social Security Number (optional)
What is the spouse’s Social Security Number?
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?
Full Legal Names and Birthdates of Children
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.
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.
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?
- SWIRCA
- Maturity Journal
- Phone Book
- Newspaper
- AVVO
- Google search
- Attorney referral
- Previous client
- Referred by friend
- Referred by client of Glenn A. Deig
- Referred by financial advisor / bank
- Referred by nursing home / assisted living
- Referred by hospital staff
- Other
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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Nursing Home — Asset Protection Intakes

Asset Protection — Client & Spouse