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Workshop Evaluation

Estate Planning Workshop Evaluation

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Spending 2-3 minutes to complete this evaluation will help us get a better understanding of your goals and enable us to save you time when planning.
Today's Date
MM slash DD slash YYYY
Referred By
Please tell us who referred you to us.
Initial so we can share this with them
Name*
First Last
Your Date of Birth
MM slash DD slash YYYY
Marital Status
- Single
- Married
- Widow(er)
Spouse Name
First Last
Spouse's Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State ZIP Code
Preferred Phone
Is this number your...
- Home
- Cell
- Work
Email*
Please indicate the effectiveness of the presenter(s):
Choose a number on the scale with 5 being Excellent and 1 being Needs Improvement
Rapport with Participants
- 5 - Excellent
- 4
- 3
- 2
- 1 - Needs Improvement
Amount of information presented
- 5 - Excellent
- 4
- 3
- 2
- 1 - Needs Improvement
Amount of new information
- 5 - Excellent
- 4
- 3
- 2
- 1 - Needs Improvement
Overall satisfaction with presentation
- 5 - Excellent
- 4
- 3
- 2
- 1 - Needs Improvement

Personal Information
Your Health
- Excellent
- Good
- Fair
- Poor
Spouse Health
- Excellent
- Good
- Fair
- Poor
Crisis Alert
- Yes
- No
Someone in my immediate family is in a Nursing Home now or is likely to be in one in the near future!
Estimated Net Worth
- < $100,000
- $100,000 - $300,000
- $300,000 - $900,000
- $900,000 +
Does this include your home?
- Yes
- No
What's Important to You?
Rate each one with a rating with 1 being LOW and 10 being HIGH
Ensure I don't lose control or access to my assets
Avoid becoming a burden to my loved ones
Having a proper Health Care Directive & Power of Attorney
Create my rule book instead of using the Government's
Protect my stuff from Government, Long-Term Care Costs, Taxes, Lawsuits
Avoid Probate
Ensure I have a plan, not just documents
Putting a professional team together to support my plan
Protecting my assets for my loved ones (from their "predators")
Other

It's Time to A.C.T.
Choose one of the following
- Free Office Appointment (Assess)
- Home Appointment, homebound only (Additional fee may apply)
- No thank you, I am not interested.
Best time to call
(Please specify)
Help Us Help You Protect Your Family
Please share contact information of those you believe may be interested in attending one of our workshops.
This person is a
- Friend
- Relative
- Colleague
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
This person is a
- Friend
- Relative
- Colleague
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
This person is a
- Friend
- Relative
- Colleague
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Share Your Thoughts
Have anything additional to share with us?
- YES, I would like to keep updated on industry changes and estate planning news.
Email
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Lawyer David Zumpano | Featured Attorney Estate Planning

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Estate Planning Law Center

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555 French Road
New Hartford, NY 13413
Phone: (315) 793-3622
Fax: (315) 793-0076

Email: clientservices@eplawcenter.com

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