Single Client Intake Questionnaire

Step 1 of 4

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Company

This field is for validation purposes and should be left unchanged.

Personal Information

Client

Name

First Last

Maiden/Other Name

Please include any maiden, prior, or other legal names.

Home Address

Street Address City State ZIP Code

Are you a resident in a facility?

Yes

Facility Name

Facility City & State

Phone

Date of Birth

MM slash DD slash YYYY

Last 4 of SSN

Please enter only the last 4 digits.

Family Status

Are you divorced?

Yes

Date of divorce

MM slash DD slash YYYY

Are you widowed?

Yes

Spouse’s name

Date of death

MM slash DD slash YYYY

Were you married at the time of their death?

Yes

Do you live with a partner?

Yes

Partner’s name

Additional Information

Please answer the questions below. If you are unsure, you may leave the answer blank.

Do you have long-term care insurance?

Yes

Not Sure

Do you have a prepaid funeral or burial plot?

Yes

Not Sure

Are you a U.S. citizen?

Yes

Not Sure

Green Card Number

Please enter your Green Card number if you are not a U.S. citizen.

Place of birth

Are you a veteran?

Yes

Service dates

Please include approximate dates if exact dates are unknown.

Financial Information

Monthly Gross Income:

Please enter approximate monthly gross income for each item that applies.

Pension

Social Security

Dividends/Interest

VA Payments

Annuities

IRA/401(k)/Roth Distributions (RMDs)

Rental Income

Other Income

Other Income Source

Please specify the source of this other income. (e.g., pension, annuity, 401k, etc.)

Do you have another source of other income to add?

Yes

Additional Other Income Source

Please specify the source of this other income. (e.g., pension, annuity, 401k, etc.)

Additional Other Income Amount

Total Monthly Gross Income

This total is calculated automatically.

Assets

Please enter each asset separately. Include the institution or company name, estimated value, and the name or names listed on the account, policy, or asset.

Checking/Savings

Institution Name

Example: Chase, Wells Fargo, Fidelity, etc.

Est. Balance

Enter approx. account balance.

Name(s) on Account

Please enter the name or names listed on this account.

Do you have another checking or savings account to add?

Yes

Institution Name

Example: Chase, Wells Fargo, Fidelity, etc.

Est. Balance

Enter approx. account balance.

Name(s) on Account

Please enter the name or names listed on this account.

Do you have a third checking or savings account to add?

Yes

Institution Name

Example: Chase, Wells Fargo, Fidelity, etc.

Est. Balance

Enter approx. account balance.

Name(s) on Account

Please enter the name or names listed on this account.

CDs

Institution Name

Chase, Fidelity, credit union, etc.

Est. Balance

Enter approx. CD balance.

Name(s) on Account

Please enter the name or names listed on this CD.

Do you have another CD to add?

Yes

Institution Name

Chase, Fidelity, credit union, etc.

Est. Balance

Enter approx. CD balance.

Name(s) on Account

Please enter the name or names listed on this CD.

401(k)/IRA/Roth IRA

Institution Name

Fidelity, Schwab, employer plan, etc.

Est. Balance

Enter approx. retirement account balance.

Name(s) on Account

Please enter the name or names listed on this retirement account.

Do you have another retirement account to add?

Yes

Institution Name

Fidelity, Schwab, employer plan, etc.

Est. Balance

Enter approx. retirement account balance.

Name(s) on Account

Please enter the name or names listed on this retirement account.

Do you have a third retirement account to add?

Yes

Institution Name

Fidelity, Schwab, employer plan, etc.

Est. Balance

Enter approx. retirement account balance.

Name(s) on Account

Please enter the name or names listed on this retirement account.

Brokerage Accounts

Institution Name

Schwab, Vanguard, Morgan Stanley, etc.

Est. Balance

Enter approx. brokerage account balance.

Name(s) on Account

Please enter the name or names listed on this brokerage account.

Do you have another brokerage account to add?

Yes

Institution Name

Schwab, Vanguard, Morgan Stanley, etc.

Est. Balance

Enter approx. brokerage account balance.

Name(s) on Account

Please enter the name or names listed on this brokerage account.

Do you have a third brokerage account to add?

Yes

Institution Name

Schwab, Vanguard, Morgan Stanley, etc.

Est. Balance

Enter approx. brokerage account balance.

Name(s) on Account

Please enter the name or names listed on this brokerage account.

Other Stocks/Bonds

Institution or Holding Name

Brokerage, transfer agent, company stock, bond issuer, etc.

Est. Balance

Enter approx. stock or bond value.

Name(s) on Account

Please enter the name or names listed on this stock or bond account.

Do you have another stock or bond account to add?

Yes

Institution or Holding Name

Brokerage, transfer agent, company stock, bond issuer, etc.

Est. Balance

Enter approx. stock or bond value.

Name(s) on Account

Please enter the name or names listed on this stock or bond account.

Life Insurance Cash Value

Insurance Company

Prudential, New York Life, Northwestern Mutual, etc.

Est. Cash Value

Enter approx. policy cash value.

Name(s) on Policy

Please enter the name or names listed on this policy.

Do you have another life insurance policy to add?

Yes

Insurance Company

Prudential, New York Life, Northwestern Mutual, etc.

Est. Cash Value

Enter approx. policy cash value.

Name(s) on Policy

Please enter the name or names listed on this policy.

Do you have a third life insurance policy to add?

Yes

Insurance Company

Prudential, New York Life, Northwestern Mutual, etc.

Est. Cash Value

Enter approx. policy cash value.

Name(s) on Policy

Please enter the name or names listed on this policy.

Other Financial Asset

Asset Description

Money owed to you, crypto, precious metals, or another financial asset.

Est. Value

Enter approx. asset value.

Name(s) on Asset

Please enter the name or names associated with this asset.

Vehicles

Please list any vehicles owned. Include the make and model, estimated value, amount owed, and the name or names listed on the registration.

Do you own a vehicle?

Yes

Make and Model

Toyota Camry, Honda CR-V, Ford F-150, etc.

Est. Value

Enter approx. vehicle value.

Amount Owed

Enter amount owed, if any.

Name(s) on Registration

Please enter the name or names listed on the vehicle registration.

Do you have another vehicle to add?

Yes

Make and Model

Toyota Camry, Honda CR-V, Ford F-150, etc.

Est. Value

Enter approx. vehicle value.

Amount Owed

Enter amount owed, if any.

Name(s) on Registration

Please enter the name or names listed on the vehicle registration.

Do you have a third vehicle to add?

Yes

Make and Model

Toyota Camry, Honda CR-V, Ford F-150, etc.

Est. Value

Enter approx. vehicle value.

Amount Owed

Enter amount owed, if any.

Name(s) on Registration

Please enter the name or names listed on the vehicle registration.

Real Property

Please list any real property owned, including a homestead, rental property, commercial property, vacation property, or property located outside Florida.

Do you own any real property?

Yes

Property Type

Property Address

Enter the street address, city, state, and ZIP code.

Est. Value

Enter approx. property value.

Mortgage Balance

Enter amount owed, if any.

Name(s) on Title

Please enter the name or names listed on the property title or deed.

Do you have another property to add?

Yes

Property Type

Property Address

Enter the street address, city, state, and ZIP code.

Est. Value

Enter approx. property value.

Mortgage Balance

Enter amount owed, if any.

Name(s) on Title

Please enter the name or names listed on the property title or deed.

Do you have a third property to add?

Yes

Property Type

Property Address

Enter the street address, city, state, and ZIP code.

Est. Value

Enter approx. property value.

Mortgage Balance

Enter amount owed, if any.

Name(s) on Title

Please enter the name or names listed on the property title or deed.

Business Interests

Please list any business ownership, partnership interest, LLC interest, corporation, or other business interest owned.

Examples: corporation, partnership, LLC, sole proprietorship, or other ownership interest.

Transfers, Payments, and Gifts

Please answer the questions below about transfers, payments, or gifts made within the last five years.

Gifts of $500 or More

Have you made any gifts of $500 or more in the last five years? If yes, please list them below.

Transfers of Property or Assets

Have you transferred ownership of any cars, real estate, or anything worth more than $1,000 without receiving reasonable payment in return? If yes, please list them below.

Cash, Check, Zelle, or Venmo Transfers

Have you transferred money to friends or relatives by cash, check, Zelle, Venmo, or similar payment methods? If yes, please list them below.

Family Details

Please include deceased and estranged children. Please provide each child’s legal name as shown on their driver license or passport.

Do you have children?

Yes

Relationship to You

Child

Stepchild

Adopted Child

Other

Name

Age

Phone

Address

Street Address City State ZIP Code

Do Any of These Apply?

Disabled

Estranged

Deceased

Minor

Spouse’s Name

Number of Children This Child Has

Ages of This Child’s Children

Please list all ages separated by commas.

Do you have another child to add?

Yes

Relationship to You

Child

Stepchild

Adopted Child

Other

Name

Age

Phone

Address

Street Address City State ZIP Code

Do Any of These Apply?

Disabled

Estranged

Deceased

Minor

Spouse’s Name

Number of Children This Child Has

Ages of This Child’s Children

Please list all ages separated by commas.

Do you have a third child to add?

Yes

Relationship to You

Child

Stepchild

Adopted Child

Other

Name

Age

Phone

Address

Street Address City State ZIP Code

Do Any of These Apply?

Disabled

Estranged

Deceased

Minor

Spouse’s Name

Number of Children This Child Has

Ages of This Child’s Children

Please list all ages separated by commas.

Do you have a fourth child to add?

Yes

Relationship to You

Child

Stepchild

Adopted Child

Other

Name

Age

Phone

Address

Street Address City State ZIP Code

Do Any of These Apply?

Disabled

Estranged

Deceased

Minor

Spouse’s Name

Number of Children This Child Has

Ages of This Child’s Children

Please list all ages separated by commas.

Do you have a fifth child to add?

Yes

Relationship to You

Child

Stepchild

Adopted Child

Other

Name

Age

Phone

Address

Street Address City State ZIP Code

Do Any of These Apply?

Disabled

Estranged

Deceased

Minor

Spouse’s Name

Number of Children This Child Has

Ages of This Child’s Children

Please list all ages separated by commas.

More than five children?

Please include any additional children’s information in the final notes section at the end of this questionnaire.

Other Family and Important People

Please list any other family members or important people we should know about.

Person #1

Name

Relationship

Address

Street Address City State ZIP Code

Phone

Do you have another family member or important person to add?

Yes

Name

Relationship

Address

Street Address City State ZIP Code

Phone

Do you have a third family member or important person to list?

Yes

Name

Relationship

Address

Street Address City State ZIP Code

Phone

Final Information

Please complete the final questions below. If a question does not apply, or you are unsure of the answer, you may leave it blank.

Estate Planning Documents

Do you have any of the following?

Will

Trust

Power of Attorney

Health Care Surrogate

How did you hear about Amy Dow Elder Law?

Is there anything else you think is important for us to know?

Personal Information

Family Status

Additional Information

Financial Information

Family Details

Final Information

Primary Offices

Primary Offices

Satellite Locations

Helpful Links

Intake Form

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