Please Complete the Appointment Form Below Estate Plan Appointment FormThank you for considering our law firm for your legal needs. It is very helpful to us to have some information prior to meeting. Please complete this intake form. If you do not know an answer or do not fully understand a question, just let us know that in the form. If you need any help, you can email law@hoplerwilms.com or call (919) 244-2019. A copy of these responses will be sent to the email address of the person completing this form. Please enable JavaScript in your browser to complete this form.Client ID (provided by Law Firm) *Please enter your Client ID for this case, which is provided by the Law Firm. Please use this ID when filling out appointment requests and completing online forms.How were you referred to us? *Please be aware that we are not currently accepting clients from MetLife Legal Plans, Legal Resources, and ARAG Legal Plans. If you have a plan with one of these insurers, please ask the insurer to provide you with another referral. NextSave and Resume LaterInformation for Primary ContactPlease provide the information for the primary contact on this case. If you are having services performed for yourself or for you and your spouse, put your information here. If you are a trusted family member or close friend assisting people with completing services and plan to participate throughout the process, put your information here. If you are completing this for another person but are not participating in the planning or logistics, then put the information for the person receiving services here.First and Last Name (of Primary Contact) *FirstLastMailing Address (of Primary Contact) *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number (of Primary Contact) *Email Address (of Primary Contact) *Please do not use company email accounts.Information for Prospective ClientPlease complete the information below about the Prospective Client. If we are performing services for a couple, please provide information about one of them. There is space further below to provide information about the spouse. If you already completed information about the person receiving services when you completed the "Primary Contact" information above, check the box indicating that.Separate Prospective ClientThe Prospective Client is the same as the Primary Contact, above.Full Legal Name (of the Prospective Client) *Please include middle names, suffixes, and variations. Mailing Address (of the Prospective Client) *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone Number (of the Prospective Client)Email Address (of the Prospective Client)Please do not use company email accounts.Current Spouse (of the Prospective Client) *There is currently a living Spouse, and they are receiving services too.There is currently a living Spouse, but they are not receiving services.There is no Spouse currently living.Information for the Spouse/PartnerTell us a little more about the Spouse of the Prospective Client.Full Legal Name (of the Spouse/Partner) *Please provide the full legal name of the spouse.Phone Number (of the Spouse/Partner)Email Address (of the Spouse/Partner)Please do not use company email accounts.Mailing Address (of the Spouse/Partner)Same as the Prospective ClientDifferent than the Prospective ClientMailing Address (of the Spouse/Partner)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePreviousNextSave and Resume LaterLegal ServicesThe information you provide here will help us guide you to the best solutions for your situation.What legal services would you like to discuss? *Preparing new estate planning documents, such as Wills, Powers of Attorney, and TrustsUpdating estate planning documents that our office preparedUpdating estate planning documents that were prepared elsewhereSpecial needs planningMedicaid or SSI benefits planningPreparing deedsOtherCheck all that apply.PreviousNextSave and Resume LaterInformation about ChildrenThe information you provide here will help us guide you to the best solutions for your situation.Does the Prospective Client, or Spouse/Partner if applicable, have children? *YesNoAt Least One Child... *is Deceased, but has no Living Descendantsis Deceased, and has Living Descendantsis currently Living and is a Minor Childhas been Adjudicated Incompetent, and has a Legal Guardian appointedis an Adult Child that is Livingreceives or may receive SSI or Medicaid due to disabilityPlease check the boxes of all the statements that apply.Names, Ages, and Information About Children *Include full names and ages of each child. Include additional details, such as if they are deceased, if they have intellectual or developmental disabilities, if they are not responsible with money, if they aren't actually a legal child but are treated as a child, or if they are a child born out of wedlock. Also, if a child of either the Prospective Client or the Spouse is not a child of the other, provide specific details.Legal ServicesThe information you provide here will help us guide you to the best solutions for your situation.What types of Assets does the Prospective Client, and Spouse/Partner if applicable, have? *At this time, we do not need a full accounting of assets, but it helps to know what types of assets you have in advance of our initial meeting.What Concerns are there about Means Tested Benefits, such as SSI or Medicaid? *If anyone involved in the planning (the person receiving services, the beneficiaries, or others) have intellectual or developmental disabilities, or receive means-tested benefits, such as Medicaid or SSI, provide details about the person, the limitations, and the benefits.Summarize the estate planning updates you'd like to discuss. *Provide thoughts on how the Prospective Client's estate, and the Spouse's estate if applicable, should be distributed after passing away? *Tell us more about the deed(s) you would like to discuss. * us Legal should Summarize what other matters you'd like to discuss. *Trusted People to Serve as AgentsProvide a list of full legal names, in the order of preference, to serve in this role, along with available contact information. If you have not come up with a list yet, that is okay. Provide your thoughts about the topic instead. Who should assist the Prospective Client, and Spouse/Partner if applicable, with financial matters in a crisis? *Who should assist the Prospective Client, and Spouse/Partner if applicable, with health care decisions in a crisis? *Who should handle the Prospective Client's final affairs, and Spouse's/Partner's final affairs if applicable, after passing away? *Who should manage the care of children in need of a guardian if the parent(s) become incapacitated or pass away? *Withdrawing Life SupportProviders are permitted to withhold life prolonging measures in NC when: (a) you have an incurable or irreversible condition that will result in your death within a relatively short period of time, (b) you are unconscious and, to a high degree of medical certainty, will never regain your consciousness, or (c) you suffer from advanced dementia or any other condition resulting in the substantial loss of cognitive ability and that loss, to a high degree of medical certainty, is not reversible.Which of these most closely matches how the Prospective Client feels about withdrawing life support? *My trusted health care agent that I name in my documents should make decisions regarding when to withdraw life support if I cannot make the decisions myself at the time.My provider should withdraw life support, even if my trusted health care agents disagree, if I cannot make the decision myself at the time.Neither of these are consistent with what I would want.Which of these most closely matches how the Spouse/Partner feels about withdrawing life support? *My trusted health care agent that I name in my documents should make decisions regarding when to withdraw life support if I cannot make the decisions myself at the time.My provider should withdraw life support, even if my trusted health care agents disagree, if I cannot make the decision myself at the time.Neither of these are consistent with what I would want.More information about withdrawing life support *Provide us with your thoughts on the topic so we can speak to you further about it.Disposing of RemainsIf you have made arrangements during your life for donating organs or parts, or for a certain disposition method, then that is followed. Otherwise, such things are typically decided by the agent making health care decisions if you have one. You can put limitations on that agent's authority, if you wish, or revoke the authority altogether. You can be as specific or as general as you would like. If you have not made decisions yet, provide your thoughts about the topic instead.What limitations, if any, should we place on the agent's authority to dispose of the Prospective Client's remains, and the Spouse's/Partner's remains, if applicable? *PreviousNextSave and Resume LaterAdditional InformationThe information you provide here will help us during the consultation.Does the Prospective Client, or the Spouse if applicable, have any physical or cognitive limitations that are relevant for this consultation? *What Additional Information should we know for this Consultation? Upload any and all files you would like us to review. Click or drag files to this area to upload. You can upload up to 10 files. You can upload previously-completed documents or other files you believe are important for us to see for the consultation. If you need to upload more than 10 files or files larger that the server permits, get in touch with our office at (919) 244-2019 or by email to law@hoplerwilms.com.Book Appointment Now? or Email Me a Link? *Proceed to Booking an AppointmentEmail me a Link to Book an Appointment LaterSubmitSave and Resume Later Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted. Copy Link Email * Send Link