Senior Center Information Questionnaire Community Name*Number of Seniors*Program Interest*Please select all that apply: Medicaid Estate Planning Trusts VA Aid and Attendance Benefit Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneEmail Website Contact InformationDirector of ProgramsName First Last PhoneEmail Executive DirectorName First Last PhoneEmail Other Pertinent PositionName First Last PhoneEmail What are good presentation topics you think would be beneficial to your clients?* Estate Planning Long Term Care/Medicaid Planning Trusts vs Wills Veteran’s Aid and Attendance Benefit Do your clients have or ask about Advance Directives? Do they need them?*Yes, they have them in place or most have them in place.No, they don’t have them in place or most don’t have them in place.OtherWhat’s your process for helping families know about applying for Veteran’s Aid and Attendance/Medicaid/Long Term Care Planning?*Many will say they just tell families what the normal facility cost is, and when the families can’t afford it they recommend the family apply for Medicaid and spend down. If this is the case, they really need an elder law attorney to help families do this just right. What attorneys or law firms do you refer to?*Would you consider referring to another qualified attorney?*If yes, let them know the experience you and the firm have and how easy it is to refer to you so they can relax knowing the family is in good hands.YesNoWould most of your clients benefit from knowing about a personal or legal guardian or ask about referrals to assist with guardianship?*Do your residents have Wills & POAs in place?*Yes, they have them in place or most have them in place.No, they don’t have them in place or most don’t have them in place.OtherWhy should families choose your Senior Program? What makes your community a good choice?*Your Contact InformationYour Name* First Last Your Email* Your Phone*PhoneThis field is for validation purposes and should be left unchanged.
