Medicaid PlanningEvaluation Form Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Cell Phone (###) ### #### Office Phone (###) ### #### Marital Status Married Divorced Widowed Single Age Group 18-30 31-45 46-60 61-75 75+ Was this information easy to understand? Yes No Would you recommend this program to others? Yes No My Current Estate Planning Document No Written Estate Plan Have a Will Have a Living Trust Other What Really Matters to Me Please rate the level of importance on a scale of 1 to 10; with 1 being “not important at all” and 10 being “very important.” Make sure there is a written plan to handle my affairs Protect my estate from Nursing Home costs Protection from Living Probate and Death Probate Minimize all death taxes Protect my estate from my children's creditors after my death Ensure my estate stays with my children if there is a divorce Protect my child with Special Needs after my death Protect my estate if my spouse gets remarried after my death Minimize income taxes on my retirement accounts Funeral planning for my final arrangements and to make it easier for my family Future Seminars If you believe this is important information for your friends, family, and groups, please help them find us. Don't worry, we won’t bother them. We’ll simply send them a personal invitation to one of our free Medicaid Planning Seminars. We can do this anonymously or on your behalf. Name (of Individual or Group) Address or Email Phone (###) ### #### (optional) Comments How did you hear of this seminar? Friend/Relative Letter Online - where? Flyer Newspaper - which one? Email Permission to Contact I authorize the law firm to contact me by text, phone, email, or mail. I understand I can withdraw permission at any time and the law firm will not sell or share my contact information with anyone. Yes No Free Personal Consultation! For all workshop attendees ($450 value!) Yes I would like a free personal consultation! Please contact me for a personal consultation in the future No cosultation, but I'd like to be on your email or mailing list for updates If you selected a free personal consultation, which of these you are interested in? New Estate Plan Plan Review Best time of day to call Best date to contact you MM DD YYYY Thank you!
