First Encounter Form - Our Family Encounter

Home
About Us
Seniors
Resources
Newsletters
Contact
952.679.8332

Menu

Home
About Us
Seniors
Resources
Newsletters
Contact
952.679.8332

First Encounter Questionnaire

Thank you for registering your emergency contact with Our Family Encounter.

Does your emergency contact know your wishes to help you in a crisis or death?
Answer the questions below to see how prepared you are.
You will receive a response with your readiness assessment after the completion and submission of this assessment.

Thank you.

Step 1

Step 1

Contact Information & Basic Details

First Name: *

Middle Initial

Last Name: *

Mailing address

City

State

Zip Code

Email Address *

Phone Number

Alt Phone Number

Your age today

Age you expect to live to live

Step 2

Step 2

Emergency Contact Information

Emergency Contact Name

Email Address

Phone Number

Alt Phone Number

Have they agreed to be your emergency contact?

Yes
No

Step 3

Step 3

Housing

If I can no longer live in my home, where do I want to live?

Apartment
50+ Community (Co-Op)
Roommates (“Golden Girls” style)
Senior Living Community
With Family
Other

Step 4

Step 4

Finances

How much money have I saved for retirement?

How much do you expect to budget for monthly expenses (includes mortgages, travel, etc.)?

Have you reviewed your beneficiary in the last 5 years?

Yes
No
Not Sure

Step 5

Step 5

Legal

Do you have a healthcare directive?

Yes
No
Not Sure

Do you have a power of attorney?

Yes
No
Not Sure

Do you have a healthcare agent?

Yes
No
Not Sure

Do you have a will/trust?

Yes
No
Not Sure

Do you have other legal services?

Yes
No
Not Sure

Step 6

Step 6

Wellness

Have you seen your doctor for a checkup in the past year?

Yes
No
Not sure
Decline to answer

Have you seen your dentist in the past six months?

Yes
No
Not sure
Decline to answer

How often do you exercise per week (number of days)?

Do you have any of these disabilities? (select all that apply)

None
Hearing
Sight
Mobility
Cognitive
Emotional

Step 7

Step 7

Socialization

What are you doing to socialize and connect with others? (select all that apply)

Live with others
Travel
Work
Have pets
Attend a faith community
Attend community events
Belong to social clubs

How close does your family or loved ones live near you? (select all that apply)

0-5 miles
6-20 miles
21-50 miles
51-200 miles
200+ miles

Do you drive?

Yes
No
Decline to answer

Do you live alone?

Yes
No
Decline to answer

Do you have pets?

Yes
No
Decline to answer

Do you travel often?

Yes
No
Decline to answer

Do you attend a faith community regularly?

Yes
No
Decline to answer

Do you attend a social/club events regularly?

Yes
No
Decline to answer

Step 8

Step 8

Celebrate Life

What have you done to plan for your funeral or celebration of life? (select all that apply)

Write an obituary
Pre-paid and planned ceremony
Pre-paid funeral planning (cemetery plot, cremation, transportation, etc.)
Purchased headstone
Provide list of who needs to be notified

Have you written or recorded your life story or legacy to share with others?

Yes
No
Not interested
Decline to answer

Step 9

Step 9

Legacy Planing

Have you shared your wishes with anyone?

Yes
No
Decline to answer

Do you have your important papers organized?

Yes
No
Decline to answer

Have you written down your online user name and passwords for website and mobile apps?

Yes
No
Decline to answer

Do you have a safety deposit box to store sensitive documents or a Payment on Death (POD) on file at your bank? POD allows your beneficiary to have access to your bank account after death.

Yes I have a Safety Deposit Box
Yes I have a POD ( Payment on Death ) on record at my bank
No to both

Share this:

Twitter
Facebook

Like this:

Like Loading...

Our Family Encounter © 2020 All Rights Reserved

Privacy Policy
Terms & Conditions

Site by JCD Promotions LLC

%d bloggers like this: