Instructions:
Please complete the following form carefully. Your responses will be used to draft your legal documents. If you have any questions, contact our office
here.
This intake form requires attention to detail and takes some time to complete, but it will save you time and expense in the long run, allowing us to move your case quickly and efficiently.
Documents included in our Simple Estate Planning Package include:
Will
Medical Power of Attorney
Medical Advance Directive to Physicians
Financial Power of Attorney
Designation of Guardian in Advance of Need
Privacy Policy
All information received in this form is strictly confidential. Our firm takes every step possible to protect your privacy. The data submitted via this form is encrypted and secured using industry-standard 256-bit SSL encryption.
The information you provide in this form will only be used to prepare your
Will,
Medical Power of Attorney, Advance Medical Directive, Financial Power of Attorney, and Designation of Guardian
documents.
If you have any questions, please don't hesitate to contact our law office. We look forward to working with you!
Contact information
Prefix
First name
*
Middle name
Last name
*
Emails
Email Address
*
Type
Upon submission, a copy of this form will be sent to the primary email.
Work
Home
Other
Primary
Default email false
Add email
Phone numbers
Phone number
Type
Work
Home
Mobile
Fax
Pager
Skype
Other
Primary
Default number false
Add phone number
What is your date of birth?
If married, what is your spouse's full legal name?
What are the full legal names of your children (born or legally adopted)?
If married, what is your spouse's preferred email address?
What county do you reside in?
Our Simple Estate Planning Package costs $900 for an individual and $1,400 for a married couple. Have you reviewed these prices and are you able to pay immediately upon scheduling your appointment? (Check or credit card is accepted)
A. Medical Power of Attorney (MPOA) Intake Form
Note:
This document allows you to appoint an
agent
to make healthcare decisions on your behalf
only if you become incapacitated
and unable to make decisions for yourself. Your agent will have the authority to communicate with medical providers and make treatment choices based on your wishes. This MPOA remains in effect until your death or until you revoke it while you still have capacity.
Client Information
Full Legal Name:
Date of Birth:
Current Address:
Agent Information
The person you appoint to
make healthcare decisions
on your behalf if you become incapacitated. Your agent is responsible for ensuring your medical wishes are followed and communicating with healthcare providers on your behalf.
Full Legal Name of Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
First Alternate Agent
(Successor)
Full Legal Name of First Alternate Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
Second Alternate Agent
(Successor)
Full Legal Name of Second Alternate Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
Scope of Authority
Grant full authority to the Agent to make all healthcare decisions on your behalf?
Yes
No
If No, specify any limitations on the Agent’s authority:
Healthcare Preferences
Life-Sustaining Treatment if Terminally Ill:
Select an option
Remove all life-sustaining treatment
Keep me alive with available treatment
Pain Management Preferences:
Organ Donation Preferences:
Additional Healthcare Instructions for Agent:
HIPAA Authorization
Authorize Agent to access medical records and speak with healthcare providers?
Yes
No
If your spouse's answers will be different to any of these questions, please explain here:
B. Advance Medical Directive (Living Will)
Note:
This document, also known as a
Living Will
, allows you to state your preferences regarding life-sustaining treatment if you are diagnosed with a
terminal or irreversible condition
and are unable to communicate your wishes. It ensures that your healthcare providers and loved ones understand your decisions about end-of-life care.
Terminal Condition Decision
(THIS SECTION DOES NOT APPLY TO HOSPICE CARE).
If your physician determines you have a terminal condition and are expected to die within six months even with treatment, what do you prefer? (Select One)
Discontinue all treatments except those needed to keep me comfortable and allow me to die naturally.
Continue all available life-sustaining treatment.
Irreversible Condition Decision
(THIS SECTION DOES NOT APPLY TO HOSPICE CARE).
If your physician determines you have an irreversible condition and cannot care for yourself or make decisions, what do you prefer? (Select One)
Discontinue all treatments except those needed to keep me comfortable and allow me to die naturally.
Continue all available life-sustaining treatment.
Additional Requests
Specify any particular treatments you do or do not want, such as artificial nutrition, intravenous antibiotics, etc. (Be sure to state whether you do or do not want the particular treatment)
If your spouse's answers to any of these questions will be different, please explain here:
C. Financial Power of Attorney (Statutory Durable POA)
Note:
This document allows you to appoint an
agent
to manage your
financial affairs
, either immediately or only if you become incapacitated. Your agent will have the authority to handle transactions such as banking, real estate, taxes, and business matters, depending on the powers you grant. This POA remains in effect until you revoke it or upon your death.
Agent Information
The person you appoint to
manage your financial affairs
under the Financial Power of Attorney. Your agent has a legal duty to act in your best interest and follow your instructions. You can grant them broad or limited authority, depending on your needs.
Full Legal Name of Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
First Alternate Agent
(Successor)
Full Legal Name of First Alternate Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
Second Alternate Agent
(Successor)
Full Legal Name of Second Alternate Agent:
Relationship to Client:
Select an option
Spouse
Child
Sibling
Parent
Friend
Other
Phone Number:
Email Address:
Effectiveness of POA
When should this POA become effective?
Select an option
Immediately
Only upon incapacity as determined by a physician
Duration of POA
Should this POA remain in effect until death?
Yes
No
Specify end date/event in the field below
If No, specify termination details:
Powers Granted
Select all that apply or select "All of the Above"
(A) Real property transactions
(B) Tangible personal property transactions
(C) Stock and bond transactions
(D) Commodity and option transactions
(E) Banking and other financial institution transactions
(F) Business operating transactions
(G) Insurance and annuity transactions
(H) Estate, trust, and other beneficiary transactions
(I) Claims and litigation
(J) Personal and family maintenance
(K) Benefits from social security, Medicare, Medicaid, or other governmental programs or civil or military service
(L) Retirement plan transactions
(M) Tax matters
(N) Digital assets and electronic communications
(O) ALL OF THE POWERS LISTED IN (A) THROUGH (N)
If your spouse's answers to any of these questions will be different, please explain here:
D. Designation of Guardian in Advance of Need
Note:
This document allows you to
pre-designate a guardian
to make decisions for you if a court determines that you are incapacitated and in need of legal guardianship. You may appoint one person to handle personal and healthcare decisions (
Guardian of the Person
) and another to manage your financial affairs (
Guardian of the Estate
), or the same person for both roles. This designation helps ensure that the court follows your wishes when appointing a guardian.
Guardian Appointments
Who is your first choice as Guardian of your person (responsible for personal care and well-being)
Who is your second choice?
Who is your first choice as Guardian of your estate (responsible for financial decisions)
Who is your second choice?
If your spouse's answers to any of these questions will be different, please explain here:
E. Simple Will
Describe the assets owned by you and your spouse. (A high-level summary is fine - no need for exact detail)
What do you estimate the value of your estate to be? If you are married you can include your spouse in this estimate.
We do not offer tax advice and generally do not handle estate planning for individuals or couples with net worth above $10 Million due to potential estate tax issues that are better handled by tax planning specialists. Do you acknowledge these limitations?
Generally, where do you want your property to go when you pass away? If you are married, include what happens after your spouses passes away as well.
Do you have a blended family or are all of your children also the children of your spouse?
Have you been diagnosed with dementia or any medical or mental issue which might cause someone to raise a question about your mental capacity to execute a will?
If your spouse's answers to any of these questions will be different, please explain here:
Do you also want us to complete a Transfer on Death Deed (TODD) so that your home or other real estate passes outside of probate at your passing?
Yes, I will provide a copy of the current deed. Cost $350
Yes, but I do not have a copy of the current deed. Cost $400
No
For most of our clients who are married, their goal is to pass all of their property to the surviving spouse and then at the death of the surviving spouse to pass all the assets to the children in equal shares. Is this your situation? If not, please explain. Example: Blended family, unique distribution plan, etc.
Do you have any questions about the estate planning process that our attorney should know about?
THANK YOU
Thank you for completing the questionnaire!
We will begin preparing your legal documents and will contact you with any updates or if additional information is needed. If you have any questions in the meantime, feel free to reach out.
Please click the
SUBMIT
button below when you have finished answering all questions.
If you are married, please have your spouse submit their own form independently. No need to answer the same questions twice though if you already answered them here!
ACKNOWLEDGEMENT AND ACCEPTANCE
I acknowledge that I have read and hereby accept the above privacy policy regarding use of my personal information.