Estate Planning Consultation Form 1Your Information2Children3Additional Information Your InformationIMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.First Name*Middle NameLast Name*Email Address* Date of Birth ** Client's Gender*Phone Number 1Phone Number 1 Description*DescriptionHomeMobileOtherPhone 1 number*Add A Second Number Add Another Phone Number Phone Number 2Phone Number 2 Description*DescriptionHomeMobileOtherPhone 2 number*Add A Third Number Add Another Phone Number Phone Number 3Phone Number 3 Description*DescriptionHomeMobileOtherPhone 3 number*Section BreakDo you have US citizenship?* Yes No Marital Status* Married Domestic Partner Unmarried IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Domestic Partner’s First Name*Domestic Partner’s Middle NameDomestic Partner’s Last Name*Domestic Partner’s Email Address* Domestic Partner’s Date of Birth * Domestic Partner’s Phone Number*Domestic partner has US citizenship?* Yes No Domestic Partner’s InformationPartner’s Gender*IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Spouse/Partner’s First Name*Spouse/Partner’s Middle NameSpouse/Partner’s Last Name*Spouse’s Email Address* Spouse/Partner’s Date of Birth * Spouse/Partner’s Phone Number*Spouse partner has US citizenship?* Yes No Spouse/Partner InformationSpouse First Name*Spouse Middle NameSpouse Last NameSpouse's Gender*Spouse/Partner’s Date of Birth * Email* Spouse/Partner’s Phone Number*Physical AddressPhysical address line 1 **Physical address line 2Physical address city*Physical State*Physical State *AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPhysical address zip/postal code*Is your Mailing Address the same as Physical Address?* My Mailing Address is the same My Mailing Address is different. I’d like to enter that address Mailing AddressMailing address line 1*Mailing address line 2Mailing address city **Mailing State ** Mailing StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Mailing address zip/postal code*Section BreakPreferred Method of Contact* By Email By Phone How many children do you have, living or deceased?*01234More than 4If you have more than 4 children let us know during the personal consultation. Child 1IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 1 First Name*Child 1 Middle NameChild 1 Last Name*Child 1 Date of Birth* Client Gender*Child 1 Email Child 1 PhoneChild 1's Parent(s)*Child 1's Parent(s) *BothPerson #1Person #2Child 1 Address Street Address Child 1 Married? Yes No Child 1's Children*Child 1's Children *01234More than 4Child 2IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 2 First Name*Child 2 Middle NameChild 2 Last Name*Child 2 Date of Birth* Client Gender*Child 2 Email Child 2 PhoneChild 2's Parent(s)*Child 2's Parent(s) *BothPerson #1Person #2Child 2 Address Street Address Child 2 Married? Yes No Child 2's Children*Child 2's Children *01234More than 4Child 3IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 3 First Name*Child 3 Middle NameChild 3 Last Name*Child 3 Date of Birth* Client Gender*Child 3 Email Child 3 PhoneChild 3's Parent(s)*Child 3's Parent(s) *BothPerson #1Person #2Child 3 Address Street Address Child 3 Married? Yes No Child 3's Children*Child 3's Children *01234More than 4Child 4IMPORTANT: Please use legal name (how it appears on your license or passport) including, middle initial, and suffix if applicable.Child 4 First Name*Child 4 Middle NameChild 4 Last Name*Child 4 Date of Birth* Client Gender*Child 4 Email Child 4 PhoneChild 4's Parent(s)*Child 4's Parent(s) *BothPerson #1Person #2Child 4 Address Street Address Child 4 Married? Yes No Child 4's Children*Child 4's Children *01234More than 4Additional Children InformationEnter Additional Children Information* My estate has the following assets: Business/Partnerships Certificates of Deposit IRA/Retirement Plans Life Insurance Real Estate Stocks, Bonds, Mutual Funds Other Are you interested in protecting assets in the event you need Long-Term care in the future?* Yes No If you would like to discuss Long-Term Care during your Initial Consult, please complete the Long-Term Care Analysis Form here: Click Here.Are you or a family member sick and contemplating a Medicaid Application?* Yes No If you would like to discuss Long-Term Care during your Initial Consult, please complete the Long-Term Care Analysis Form here: Click Here.Enter Additional Questions*Where did you hear about us?*An Email I ReceivedBlog / FacebookInternet / Search EngineLanding Pages – Estate PlanningRadio and TVLink from another web siteMailing / PostcardNewsletterNewspaperOtherReferralWho you were referred by?*Other – Where did you hear about us?*Approximate gross value of my estate*Select value of my estate$0 to $100,000$100,000 to $500,000$500,000 to $1,000,000$1,000,000 to $4,000,000Over $4,000,000I have concerns about a Special Needs family member:* Yes No What is the main concern/reason you would like to meet with an attorney?* Δ