Date________________ Home Phone No._____________________ Business Phone No. ___________________
This form is extremely important. Your accuracy and completeness in responding will help me best represent you.
Bring this information with you to the appointment.
A. PERSONAL DATA
Full Name___________________________________________________________________________________
(print name as shown on your checks)
Street Address ________________________________________________________________________________
City__________________________________________________________ State___________ Zip____________
Birth Date_____________________________________ Social Security No.____________________________
U.S. Citizen? Yes ___ No ___ Veteran? Yes ___ No ___
If widowed, please list date of death of spouse______________________________________________________
Was your former spouse a Veteran? Yes ___ No ___
B. MEDICAL DATA
1. HEALTH
Diagnosis ___________________________________________________________________________________
Prognosis____________________________________________________________________________________
Course of Treatment___________________________________________________________________________
If you are already in a nursing home, please indicate the name of the nursing home and the date first entered______________________________________________________________________________________
2. PHYSICIAN
Full Name of Primary Physician _________________________________________________________________
Street Address________________________________________________________________________________
City_________________________________________________________ State__________ Zip______________
3. STATE PHARMACEUTICAL PLAN
Are you currently on PAAD (Pharmaceutical Assistance to the Aged and Disabled Program) or any other state pharmaceutical plan? Yes ___ No ___
C. MONTHLY INCOME
Social Security Benefits $___________________
(include $43.80 Medicare Part B
Deduction, if applicable)
Retirement Benefits (Gross) $___________________
Veterans Disability Income $___________________
Annuity Income $___________________
Rental Income $___________________
TOTAL MONTHLY INCOME $___________________
If there is a pension, please list the gross pension amount, including any monies taken out for federal income taxes, health insurance, or any other reason.
Could this pension amount increase in the future? Yes ___ No ___
Do not include interest and dividend income on this form.
D. MONTHLY COST OF NURSING HOME
Monthly Nursing Home Cost $___________________
Monthly Prescription Cost $___________________
Monthly Incontinent Cost $___________________
Monthly Other Cost $___________________
Total Monthly Cost $___________________
The nursing home is paid through _________________________________________________(month/year).
E. ASSETS/LIABILITIES
Please insert the value of each asset/liability in the appropriate space.
ASSET/LIABILITY
ASSET TOTAL
LIA-BIL-I-TY TOTAL
PERSONAL EFFECTS
CHECKING ACCOUNT
SAVINGS ACCOUNT
MONEY MARKET ACCOUNT
CERTIFICATES OF DEPOSIT
RESIDENCE (ASSESSED VAL-UE)
BLOCK#___________ LOT#___________
(Ob-tain from Tax Bill)
OTHER REAL ESTATE
AUTOMOBILE(S)
MUTUAL FUNDS
STOCKS
BONDS
ANNUITIES
CASH VALUE - LIFE INSURANCE
IRA
NURSING HOME DEPOSIT
OTHER
OTHER
TOTAL
What did you pay for your current home including any improvements? $_____________________________
Address of any real property other than personal residence:
(1)Street ________________________________________City ______________State________Zip___________
Tax Block # , Lot # (Can be obtained from Tax Bill)
What did you pay for this property including any improvements? $_____________________________________
(2)Street ________________________________________City ______________State________Zip___________
Tax Block # , Lot # (Can be obtained from Tax Bill)
What did you pay for this property including any improvements? $_____________________________________
Name of Homeowner's Insurance Company________________________________________________________
Street Address________________________________________________________________________________
City_________________________________________________________ State__________ Zip______________
Phone No.___________________________________ Policy No._________________________________
F. GIFTS
Please list gifts made in excess of $3,000 in any one month, to an individual or group of individuals, within the past 36 months:
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
Recipient___________________________________ Date ______________ Amount ____________
G. LIFE INSURANCE
COMPANY NAME
(include address and policy #)
TYPE
DEATH
BENEFIT
VALUE
FACE VALUE
CASH VALUE
INSURED
OWNER
BENEFICIARY
(Include the cash value of the life insurance on the life insurance line in Section E)
It is very important to know the cash value and the death benefit of your life insurance policy. To obtain the cash value of the policy, please call your insurance agent, or call the insurance company directly.
H. CHILDREN (if applicable)
| CHILD'S NAME | ADDRESS (WITH ZIP CODE ) |
TELEPHONE NUMBER | DATE OF BIRTH | SOCIAL SECURI-TY NUMBER |
Are all of your children in good health? Yes ___ No ___ Are any of your children blind? Yes ___ No ___ Are any of your children disabled? Yes ___ No ___ Are any of your children receiving SSI or other form of government entitlement? Yes ___ No ___ Do any of your family members have any problems with: Aids? Yes ___ No ___ Drug Addiction? Yes ___ No ___ Alcoholism? Yes ___ No ___ Spendthrift? Yes ___ No ___ Do any of your children live with you in your home? Yes ___ No ___ If yes, name of child________________________________________________________________________ Does a sibling live in your home with you? Yes ___ No ___ If yes, name of sibling_______________________________________________________________________ I. MISCELLANEOUS Do you have any other legal issues which I should be aware of: Yes ___ No ___ If yes, please explain __________________________________________________________________________ ___________________________________________________________________________________________ J. REFERRAL By Whom Were You Referred To This Office? Name _______________________________________________________________________________________ Street Address________________________________________________________________________________ City_________________________________________________________ State__________ Zip______________ K. CERTIFICATION The undersigned hereby represents to Beasley & Ferber P.A., and each of its attorneys that the information contained in this intake form is accurate and complete, and that the undersigned understands that the law firm and its individual lawyers will rely on this information. I understand that if the information contained herein is inaccurate or incomplete, the recommendations made by the law firm may not be appropriate. Signature of Client or Client Representative: ____________________________________________________