Individual Intake Form Please fill out the form below to the best of your ability. If you prefer to fill out the form over the phone, please call 978-750-0386 Full Name (Including Middle Initial) * Gender * Male Female Other Marital Status * U.S. Citizen? * Yes No Do they currently receive Social Security, a pension or any other income? * Please list all Do they have Medicare? * Yes No Any supplemental health insurance or prescription plan coverage? * Yes No Do they own any life insurance policies? If so, how many? * Do they own a Long Term Care policy? * Yes No Do they have prepaid funeral plans? * Yes No Do they own any property or have they in the last 5 years? If yes, please provide address and if it has been sold, provide date sold. * Living situation prior to facility. * Do they own a car? * Yes No Are they the grantor/trustee or beneficiary of any trust? * Yes No Do they own a checking account? How many? * Do they own a savings account? How many? * Do they own any of the following? * CD's Stocks Bonds Annuities IRA's Securities Accounts Total Amount of Assets * Have they closed any accounts (including CD’s/IRA’s, etc.) in the last 5 years? If yes, please list types of accounts and dates closed. * Have they filed taxes in the last 2 years? * Yes No Have they gifted money/property/car in the last 5 years? * Yes No Do they have any significant credit card or IRS debt? * Yes No Who is their Durable Power Of Attorney (DPOA)? * Who is their Health Care Proxy? * What is YOUR mailing address? * Address 1 Address 2 City State/Province Zip/Postal Code Country Today's Date * MM DD YYYY Thank you!
