Workshop Evaluation Form
Date of Workshop Attended
I attended a Video Replay with
Spouse ( if applicable)
Apartment, suite, etc
ZIP / Postal Code
Work or Cell Phone
80 and over
What topic discussed did you most enjoy or get value from?
What is your greatest financial concern?
The material presented in the workshop was:
Understandable and helpful
Not relevant to my needs
I/we (or a family member) are facing the following situation(s) that attention:
Long-term care facility resident
Veteran or widowed spouse with substantial out-of-pocket medical or care expenses (now or anticipated)
Memory loss, Alzheimer's, Parkinson's, MS, ALS, stroke or other medical concern that is or may be associated with a need for long-term care
I/we want to protect my/our life savings from being lost to future long-term care expenses
Would this planning be for someone other than yourself?
If so, please indicate their Name(s) and relationship to you:
Yes, I/we want to obtain a FREE telephone evaluation of my/our situation. Please send me/us a confidential Elder Law Planning Questionnaire to complete so that you can provide the evaluation