Section 1.9 Client’s Personal Information

• Library: Elder Law 2015 Forms

ABC Law Firm

123 First Street

Anytown, Missouri 64444

(816) 555-1212

Client Questionnaire

(Medicaid Planning)

To help us better serve you, please fill out this questionnaire. Be as specific as possible. The more information you are able to provide us, the better we will be able to assist you. Thank you.

Date

Name ________________________________ Spouse

Husband’s Birthdate __________________ Soc. Sec. #

Wife’s Birthdate ______________________ Soc. Sec. #

Address

City _______________________________ State ___________________ Zip

Phone Home (_____) _______________________ Work (_____)

Place of Employment

Are you a veteran? _________ If so, dates of service:

Please list all family members and significant others:

Name Relationship (e.g., child, friend, other) Age

Have you or your spouse been married previously? _____________________________________

If yes, are there children from the prior marriage(s) who are not listed above? ________________

Do you or your spouse have any health-related concerns we should be aware of...