(Powers Of Attorney) Questionnaire 2025 | The Law Office of Kelly T. Braun, PLLC
This form asks for information about the potential client - all of which is kept confidential. Providing this information before we meet is helpful to make the most of our time when discussing healthcare and general powers of attorney documents. Thank you for taking the time, Kelly (If you are looking for documents for more than one person, please complete and send separate questionnaires.) PLEASE NOTE: There is no attorney-client relationship created by completing and submitting this form.
Full Name (First, Middle, Last)
Date of Birth
Email - potential Client
Phone Number - potential Client
Permanent (home) Address
Is the potential client a young adult? (Check all that apply)
Yes - recently or soon to be 18 years old
Yes - attending or heading to college in-state
Yes - attending or heading to college out-of-state
Yes - living at home; attending local school
Yes - other
No
School (other) Address
Where will you live while in school?
Dormitory
Apartment - leasing
My parent's home
Co-Op
Fraternity/Sorority House
Other
N/A - I am not student
Name(s) of Parents/Legal Guardian(s)
Email - Parent/Guardian
Phone Number - Parent/Guardian
Parent/Guardian's address (Complete only if different from your permanent address)
Marital Status - potential Client
Single; never married
Single; divorced/widow(er)
Married
Separated
What documents do you want to discuss? (Select all that apply)
Healthcare Power of Attorney; HIPAA Authorization
General (Education/Finances/Property) Power of Attorney
Will (Simple)
Powers of Attorney to Care for Minors (temporary; not to exceed 6 months)
Other
What is the reason for the documents? (Select all that apply)
Turning/just turned 18
Leaving for college
Moving out of state
Health issues
Vacation planned
Other
Information about potential client? (Select all that apply)
Attends or will be attending college
Applied, applying for, or receives financial aid
Participates in sports
Member of travel team for sports
Participates in other activities where travel is required
Studying or plans to study abroad
Known allergies or allergic reactions
Receives ongoing Medical Treatment
Moving out of state
I want to donate organ(s) or any part of my body for transplantation to another person
Someone other than my parent(s) will be my initial Agent(s)
Current Estate Planning Documents (Select all that apply)
None
Will
Healthcare Power of Attorney
General Power of Attorney
Trust
Other
When are you looking to have these document(s) done?
How soon are the documents needed? (generally this is a 2-3 week process)
By a certain date
Within the next month
Within the next couple of months
Sometime this year (2022)
Who is being considered to name as the agents (under each power of attorney) for the potential client?
Mother
Father
Mother and Father together
Other family member(s)
Other individual(s)
To Be Determined
Is there additional information that you consider relevant to our discussion?
I understand that completing and submitting this form does not create an attorney-client relationship with attorney Kelly T. Braun or The Law Office of Kelly T. Braun, PLLC.
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