Intake Professional Svs

This form will help us understand your current situation and goals, allowing us to provide tailored referrals to trusted professionals in estate planning, financial planning, and life insurance. All information provided will be kept confidential.

Professional Services Referral Intake Form

Primary Contact / Responsible Party Information

If different from client, or if client needs assistance with decision-making

Are you legally authorized to make decisions for the client? *? If yes, please specify (e.g., Power of Attorney, Guardianship):

General Situation & Goals

What prompted you to seek referrals for professional services at this time? * ? (e.g., recent life event, desire for comprehensive planning, family discussion)

What are your primary goals for this consultation? * ? (Please check all that apply and elaborate below)

Estate Planning Needs

Do you currently have a Will? * ? If yes, when was it last reviewed/updated?

Do you have a Durable Power of Attorney for Finances? * ? If yes, who is appointed?

Do you have an Advance Directive for Healthcare? * ? (Living Will/Healthcare Power of Attorney)? (Yes/No) If yes, who is appointed?

Financial Planning Needs

Are you currently working with a Financial Advisor? *? If yes, name/firm:

What are your primary sources of income? * ? (e.g., Social Security, pension, investments, part-time work)

Do you have a clear understanding of your current assets and liabilities? * ? (e.g., bank accounts, investments, real estate, debts)

What are your retirement goals? *? (e.g., travel, staying in home, specific lifestyle)

Life Insurance Needs

Do you currently have any life insurance policies? *? If yes, please list provider(s) and policy type(s) if known:

What is the primary purpose of your current or desired life insurance coverage? * ? (e.g., cover final expenses, leave an inheritance, provide for a spouse/dependent, charitable giving)

Do you understand the different types of life insurance and which might be suitable for you? * ? (e.g., Term, Whole Life, Universal Life)

Health & Medical Background

Relevant for life insurance underwriting and long-term care planning

List any current medications * ? (including over-the-counter and supplements)

Have you had any recent hospitalizations or major medical events? *? If yes, please describe:

Preferences for Referrals

Do you have any preferences regarding the location of the professional's office? * ? (e.g., local, virtual)

Are there any specific qualifications or characteristics you are looking for in a professional? * ? (e.g., fee-only advisor, specific designations)

Client Information

Veteran Status *? If yes, please list branch and dates of service:

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Thank you for reaching out. We know how important these care decisions are for your family. One of our Senior Care Experts will review your message and call you within 24 hours to discuss how we can help. In the meantime, you can find our Family Video Guides Here.
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