** Confidential Planning Information for Couple – Short Form **
For use by Elder Law of East Tennessee
Amelia G. Crotwell, Sarah E. C. Malia, & Bailey M. Schiermeyer, Attorneys
We are located at 903 N. Hall of Fame Drive, Knoxville, TN 37917
These questions pertain to the persons, Husband and Wife, for whom we are planning. We ask a lot of
questions on this form because we need a lot of information about you for our planning. Do your best, but do not worry
if some of the information is not available to fill in or applicable to you.
Please call us at (865) 951-2410 if you have any questions or concerns about completing this form.
Date of Consultation:
Referred by:
1. Personal Information
Husband
Wife
As name appears on
social security card.
As name appears on
social security card.
SSN:
SSN:
Date of birth:
Date of birth:
Place of birth:
Address:
City, state, zip
Home county:
Email:
Primary phone: #
☐Home
☐Cell
☐Work
#
Secondary
phone:
☐Home
☐Cell
☐Work
U.S. Citizen?
☐ Yes ☐ No
Veteran?
Registered to
vote in TN?
☐ Yes ☐ No
Place of birth:
Address if different:
City, state, zip if
different
Home county if
different:
Email:
Primary phone: #
☐Home
☐Cell
☐Work
#
Secondary
phone: ☐Home
☐Cell
☐Work
U.S. Citizen?
☐ Yes ☐ No
Veteran?
Registered to
vote in TN?
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
Contact Information (Indicate the method(s) you would prefer we use when contacting you. Mark all that
apply.)
Husband: ☐ Email
Wife:
☐ Email
☐ Primary Phone
☐ Primary Phone
☐ Secondary Phone
☐ Secondary Phone
Are there any special instructions regarding these methods of contact? (e.g. Call only after 5pm.)
Is there anyone we should NOT contact?
If not you, who is your “Contact Person(s)” to discuss appointments and any other information about you? Provide their
name(s), address, phone number, and email.
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1
Marriage Information
Date & place of marriage
Was either party married previously?
☐ Yes
☐ No
2. Children (from all marriages)
Name:
Name:
Address:
Address:
Phone:
Email:
Spouse:
Phone:
Email:
Spouse:
Children:
Children:
Name:
Name:
Address:
Address:
Phone:
Email:
Spouse:
Children:
Phone:
Email:
Spouse:
Children:
Name:
Name:
Address:
Address:
Phone:
Email:
Spouse:
Children:
Phone:
Email:
Spouse:
Children:
Do you have any dependents (someone who depends on you, in whole or in part, for support)?
☐Yes
☐No
If yes, who?
Are any of your children receiving Supplement Security Income or Social Security Disability; or if not, do they have any
major disabilities?
☐Yes ☐No
If yes, who?
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2
3. Health Information
Husband
What medical or health problems
do you currently have?
What medical problems have you
had in the past?
Wife
What medical or health problems
do you currently have?
What medical problems have you
had in the past?
4. Functional Limitations and Support
“Activities of daily living” refers to the basic tasks of everyday life. When people are unable to perform these activities,
they need help in order to cope. This help can come from other human beings, mechanical devices (for example, a
walker or wheelchair), or both human and mechanical aid. We request this information because the more assistance people need with their daily activities, the more likely they are to need additional help in their home or to consider some
other living arrangement; to use hospitals and doctors; and to die sooner rather than later.
Husband: Place an X in the box that reflects how often you need assistance with the following activities.
Activities of Daily Living
Activity
Always
4-6 Days/Week
Bathing
☐
☐
Dressing
☐
☐
Transferring (e.g. bed to chair)
☐
☐
Walking/mobility
☐
☐
Feeding self/eating
☐
☐
Grooming
☐
☐
Using the toilet
☐
☐
Behaviors (e.g. elopement, agitation, acting out)
☐
☐
Can express needs
☐
☐
Can follow directions
☐
☐
1-3 Days/Week
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Never
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Place an X in the box that reflects how often you need assistance with the following activities.
Instrumental Activities of Daily Living
Activity
Always
4-6 Days/Week
1-3 Days/Week
Never
Using the telephone
☐
☐
☐
☐
Getting out by car or public transport
☐
☐
☐
☐
Grocery shopping
☐
☐
☐
☐
Preparing meals
☐
☐
☐
☐
Doing housework or handyman work
☐
☐
☐
☐
Taking medications
☐
☐
☐
☐
Managing money
☐
☐
☐
☐
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Place an X in the box that best reflects how often you are aware of or can accurately recognize people, the place where
you are, & the time.
Orientation
Always
4-6 Days/Week
1-3 Days/Week
Never
Oriented to person
☐
☐
☐
☐
Oriented to place
☐
☐
☐
☐
Oriented to time
☐
☐
☐
☐
If anyone provides you with assistance or caregiving, please provide their name(s), your relationship with them, what days
of the week assistance is provided and for how many hours, and how the assistance is provided:
Is there any durable medical equipment being used?
☐Yes
☐No
If yes, what is it and where is it located?
Are there any ambulation aid devices (walker, cane, etc.) being used?
☐Yes ☐No
Is there a wheelchair or scooter in use? ☐Yes ☐No
Is there any other medical equipment in the home (hospital bed, oxygen, hoyer lift, air mattress)? ☐Yes
☐ No
If yes, list:
How many falls have you had in the last 6 months?
When did they happen?
Do you wear a hearing aid?
Do you have vision impairment?
Do you wear glasses?
Do you have speech impairment?
☐Yes
☐Yes
☐Yes
☐Yes
Were you injured? ☐ Yes ☐ No
☐No
☐No
☐No
☐No
Place an X next to the situation you are currently living in:
☐Single-family home with no assistance
☐Single-family home but someone assists with above activities
☐Apartment or retirement living community
☐Assisted-living facility
☐Nursing home
☐Other:
Since when have you lived here?
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Wife: Place an X in the box that best reflects ability to complete the following activities of daily living.
Activities of Daily Living
Activity
Always
4-6 Days/Week
Bathing
☐
☐
Dressing
☐
☐
Transferring (e.g. bed to chair)
☐
☐
Walking/mobility
☐
☐
Feeding self/eating
☐
☐
Grooming
☐
☐
Using the toilet
☐
☐
Behaviors (e.g. elopement, agitation, acting out)
☐
☐
Can express needs
☐
☐
Can follow directions
☐
☐
1-3 Days/Week
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Never
☐
☐
☐
☐
☐
☐
☐
☐
☐
☐
Place an X in the box that best reflects ability to complete the following activities of daily living.
Instrumental Activities of Daily Living
Activity
Always
4-6 Days/Week
1-3 Days/Week
Never
Using the telephone
☐
☐
☐
☐
Getting out by car or public transport
☐
☐
☐
☐
Grocery shopping
☐
☐
☐
☐
Preparing meals
☐
☐
☐
☐
Doing housework or handyman work
☐
☐
☐
☐
Taking medications
☐
☐
☐
☐
Managing money
☐
☐
☐
☐
Place an X in the box that best reflects how often you are aware of or can accurately recognize people, the place where
you are, & the time.
Orientation
Always
4-6 Days/Week
1-3 Days/Week
Never
Oriented to person
☐
☐
☐
☐
Oriented to place
☐
☐
☐
☐
Oriented to time
☐
☐
☐
☐
If anyone provides you with assistance or caregiving, please provide their name(s), your relationship with them, what days
of the week assistance is provided and for how many hours, and how the assistance is provided:
Is there any durable medical equipment being used?
☐Yes
☐No
If yes, what is it and where is it located?
Are there any ambulation aid devices (walker, cane, etc.) being used?
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☐Yes ☐No
Is there a wheelchair or scooter in use? ☐Yes ☐No
Is there any other medical equipment in the home (hospital bed, oxygen, hoyer lift, air mattress)? ☐Yes
☐ No
If yes, list:
How many falls have you had in the last 6 months?
When did they happen?
Do you wear a hearing aid?
Do you have vision impairment?
Do you wear glasses?
Do you have speech impairment?
☐Yes
☐Yes
☐Yes
☐Yes
Were you injured? ☐ Yes ☐ No
☐No
☐No
☐No
☐No
Place an X next to the situation you are currently living in:
☐Single-family home with no assistance
☐Single-family home but someone assists with above activities
☐Apartment or retirement living community
☐Assisted-living facility
☐Nursing home
☐Other:
Since when have you lived here?
5. Resources
Monthly Gross Income (income before deductions)
Do not list interest or dividend income. Do not list your net income.
Husband Gross Amount
Husband Deductions
Wife Gross Amount
Source
(before deductions)
Wife Deductions
(before deductions)
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
IRA Distribution
$
Annuity Payment
Other:
$
________________
Total $
$
$
$
$
$
$
$
$
$
$
$
$
Wages
Social Security
Retirement Pension
VA Pension or
Benefit
Personal Residence
Property Address:
Names (as they appear on deed):
Date Acquired:
Current Value:
$
Mortgage Company:
ELET – Revised 9 February 2016
Purchase Price:
Tax-Appraised Value:
Mortgage Balance:
6
$
$
$
Other Real Estate
1. Property Address:
Names (as they appear on deed):
Date Acquired:
Current Value:
$
Mortgage Company:
Purchase Price:
Tax-Appraised Value:
Mortgage Balance:
$
$
$
2. Property Address:
Names (as they appear on deed):
Date Acquired:
Current Value:
$
Mortgage Company:
Purchase Price:
Tax-Appraised Value:
Mortgage Balance:
$
$
$
Other Assets (These are your bank accounts, CDs, annuities, stocks, retirement plans, life insurance, etc.)
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
$
$
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
$
$
$
$
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
$
$
$
$
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
$
$
$
$
Type of Asset:
Company Name:
Value:
Initial Investment:
Name(s) on Account:
Beneficiary:
$
$
Total Value of Other Assets: $
(If you have additional items, feel free to copy this page and attach with the rest of the packet.)
ELET – Revised 9 February 2016
7
List large items of personal property you own (cars, boats, RVs, farm equipment, etc.) or any valuable collections (antiques, coins and stamps, guns, etc.):
Item:
Value:
$
Item:
Value:
$
Item:
Value:
$
Item:
Value:
$
Item:
Value:
$
Husband: Do you have a prepaid funeral or burial?
If yes:
☐ Yes ☐ No
Funeral Home: _______________________________Phone #: _______________________
Location of Plot: ______________________________ Value of Plot: $ __________________
Wife: Do you have a prepaid funeral or burial? ☐ Yes ☐ No
If yes:
Funeral Home: _______________________________Phone #: _______________________
Location of Plot: ______________________________ Value of Plot: $ __________________
Have you made any gifts or transfers over $500.00 to any person or trust in the past 60 months? ☐ Yes
☐ No
If yes, please provide the indicated information for each gift or transfer:
To Whom:
Date of Gift:
Item:
Value:
To Whom:
Date of Gift:
Item:
Value:
$
To Whom:
Date of Gift:
Item:
Value:
$
$
To Whom:
Date of Gift:
Item:
Value:
$
6. Estate Planning
Check any of the following documents you have. Please bring these documents to our meeting.
Document
Durable Power of Attorney
Husband
☐ Yes ☐ No
Wife
☐ Yes ☐ No
Health Care Power of Attorney
☐ Yes ☐ No
☐ Yes ☐ No
Living Will
☐ Yes ☐ No
☐ Yes ☐ No
Last Will and Testament
☐ Yes ☐ No
☐ Yes ☐ No
Revocable Living Trust
☐ Yes ☐ No
☐ Yes ☐ No
Name of person completing the form:
ELET – Revised 9 February 2016
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