ONLINE FORM Long-Term Care Intake Step 1 of 4 25% Contact InformationPlease provide the following information about yourself then click NEXT to provide details about the long term care applicant.Your Name(Required) First Middle Initial Last Phone(Required)Relation to Applicant(Required) Referral Source(Required) Applicant InformationName(Required) First Middle Last Suffix Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone(Required)Cell Phone(Required)Email(Required) Date of Birth(Required) MM slash DD slash YYYY Marital Status?(Required) Married Single Divorced Widowed Spouse Name(Required) Married Previously?(Required) Yes No Previous Spouse Name(Required) Served in the military?(Required) Yes No Dates of Service(Required) Spouse Served in the military?(Required) Yes No Spouse Dates of Service(Required) Citizen of Michigan?(Required) Yes No State in which the Applicant is a Citizen(Required) Resident of Michigan?(Required) Yes No State in which Applicant Resides(Required) Children of Applicant(Required)First NameMiddle InitialLast Name Add RemoveUse to Plus (+) on RIGHT to Add More. Max 4. Applicant Health InformationBrief Summary of Applicant's Current Medical Condition:(Required)Has the Applicant been Certified Incapacitated by two (2) or more Medical Doctors?(Required) Yes No The Applicant is Currently in a:(Required) Hospital Nursing Home Rehabilitation Facility None of the Above HiddenFacility InfoFacility Name(Required) Admission Date(Required) MM slash DD slash YYYY Facility Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Estate PlanDoes the Applicant have an Estate that Exceeds $800,000 (not counting home values)?(Required) Yes No Estate Planning Documents: Does Applicant have any of the estate planning documents in place?Last Will and Testament?(Required) Yes No Fiduciary(s) for Last Will and Testament(Required)First NameMiddle InitialLast Name Add RemoveUse to Plus (+) on RIGHT to Add More. Max 2.Trust?(Required) Yes No Fiduciary(s) for Trust(Required)First NameMiddle InitialLast Name Add RemoveUse to Plus (+) on RIGHT to Add More. Max 2.Durable Power of Attorney (DPA)?(Required) Yes No Fiduciary(s) for DPA(Required)First NameMiddle InitialLast Name Add RemoveUse to Plus (+) on RIGHT to Add More. Max 2.Patient Advocate Designation (PAD)?(Required) Yes No Fiduciary(s) for PAD(Required)First NameMiddle InitialLast Name Add RemoveUse to Plus (+) on RIGHT to Add More. Max 2.Guardianship/Conservatorship?(Required) Yes No Guardian/Conservator Name:(Required) First Middle Initial Last Court in which Guardianship/Conservatorship was Issued(Required) Form CompletePlease click SUBMIT below to send the information you provided to Morello Law Group, P.C.Should we email you a copy of this form?(Required) Yes No Email to Send Copy(Required) Enter Email Confirm Email
