Questionnaires and Forms
| Estate Planning Questionnaire
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(Short Form, emphasis on Medicaid Planning) | ||
| Spousal Impoverishment Worksheet
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Married couple, 1 spouse requiring nursing care in facility or in home, Medicaid payor source | ||
| ThompsonMcMullan Estate Plan Questionnaire (Long Form)
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| Will Questionnaire
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Short Form | ||
| Power of Attorney / Advance Medical Directive Questionnaire Scope of Care Requests (SOCR)
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| Third party Self-Administered Gerocognitive Exam (SAGE) | Credit to Ohio State University | Quick | |
| Mini-Mental Status Examination (MMSE) (aka Folstein) Online Test
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Background | ||
| Guardianship Questionnaire
Non-Confidential Legal Services Inquiry for Guardianship Assistance |
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| Special Needs Trust Questionnaire | |||
| Virginia Hospital Association Advance Directive
VSB Advance Medical Directives VSB Endorsed Medical Directive (PDF)
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VHA form and instructions.
Caveat: “This form includes the special power in which you can give your health care agent the power to agree to treatment even when you are objecting to that care.” See page 3. Warning: When last reviewed none of the VSB forms contains the grantor’s consent to being taken into temporary custody over his objection and transported to a hospital for mental or physical treatment. Without this language, law enforcement officers may refuse to transport the grantor to avoid civil liability for false imprisonment. The same concerns will apply to civilians taking the grantor into custody. “To prevail in an action for false imprisonment, a plaintiff must prove that her liberty was restrained, either by words or acts that she would fear to disregard, and that there was no sufficient legal excuse to justify the restraint. Montgomery Ward & Co. v. Wickline , 188 Va. 485, 489, 50 S.E.2d 387 (1948) ; Lewis , 281 Va. at 724, 708 S.E.2d 884. ‘False imprisonment is restraint of one’s liberty without any sufficient cause therefor[; it is not essential that a person is] confined in jail or in the custody of an officer.’ Zayre of Va., Inc. v. Gowdy , 207 Va. 47, 50-51, 147 S.E.2d 710 (1966).” Shirley v. Kroger Ltd. P’ship I, 300 Va. 99, 860 S.E.2d 372 (2021).
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| Psychiatric Advance Directive Form (RSM Form)
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Complete “Protest” form | ||
| Ulysses Clause: Amending Existing Advance Medical Directive (Courtesy of John Oliver, Esq.) | Supplemental, for existing advance medical directive. Click here for required certifying health licensee listing (54.1-2986.2 (B)(1). | ||
| Artificial Ventilation / Ventilator Advance Directive Supplement (Developed with John Oliver, Esq.) | Inspired by COVID 19 Pandemic, this form supplements but is not dependent upon any existing advance medical directive and speaks directly to ventilation issues for serious cases of the virus. | ||
| Virginia Advance Directory Registry
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Use this link to create an online repository for advance directives and powers of attorney. You may remove them at any time. Remember your password! | ||
| Guardian ad litem Checklist for Required Notice and Report |
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| Official Circuit Court Probate Forms |