Workshop Evaluation Form
Date of Workshop Attended
Month
Day
Year
I attended a Video Replay with
Kaye Dent
Wes Coulson
N/A
Name
Spouse ( if applicable)
Street Address
Apartment, suite, etc
City
State/Province
ZIP / Postal Code
Home Phone
Work or Cell Phone
Email Address
Your Age(s)
Under 50
50-59
60-69
70-79
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:
Too basic
Understandable and helpful
Too complicated
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?
Yes
No
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
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