QUESTIONNAIRE

Please complete this questionnaire prior to our consultation. The more accurate and complete you answer the questions, the more productive our meeting will be.

List the value of each of the assets (including liabilities) of the chronically ill elder , if any, as described below: Indicate if jointly owned and with whom.

List the value of the assets (including liabilities) for the spouse of the chronically ill elder, if any, as described below: Indicate if jointly owned and with whom.

Please list all household expenses on a monthly basis as described below: