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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
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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

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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.
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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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