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Kathy Kestler
Monica Pascual
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Home
Services
Our Story
Meet our Team
Robbie Caron
Kathy Kestler
Monica Pascual
Medicaid Benefits
Living Options
Resources
Contact
Blog
Newsletter
Intake Form
Consult Date
(Required)
MM slash DD slash YYYY
Time
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Referred By
Organization
Lorem 1
Lorem 2
Lorem 3
Lorem 4
Lorem 5
Caller Name
(Required)
Caller Phone
(Required)
Caller Email
Caller Relationship
Caller Address
Other Contact
Client Name
Age
Facility Location/Date Admitted
Facility Address
Home Address
Client Phone
Email Address
Dx:
Mcr#
Disenroll
Yes
No
MCD Approved
Is there a POA in place?
Yes
No
Needed
Marital Status
Married
Widowed
Single
Divorced
Spouce Name
Mcr#
Spouse's Age
MCR Adv. plan
Disenroll
Yes
No
Veteran or Spouse of Veteran?
Yes
No
Needed
Social Security Income: Income Limit is $2,901.00 for 2025
Pension
VA
IRA RMD Monthly Distribution
Long-Term Care Policy
Other
Projected Monthly Gross Income
If Over Income Limit then QIT required
Yes
No
OIT Needed
Spouses can sign QIT if no POA
Real Estate Property
Car
Yes
No
Can have 2 cars if over 7 years old
Assets
List all investments/retirement accounts
Bank Accounts Check
Bank Accounts Check
Bank Account Savings
IRA
C.D./Stocks/Bonds/Annuities
Life Insurance
Spouse Life Insurance
Burial Account
Projected Gross Total Assets = $
Single person allowed House/Car and $2,000 assets. Community Spouse allowed House/Car and $154,000.
Lawyer working with
John Williams
Alan Reinfeld
Other
Lawyer working with Other
Lawyer Consultation Needed for
POA
QIT
PSA
DEED
Spousal Diversion
Spousal Refusal
Pooled Trust
Attorney Price Note
M&M Price Quote $
Notes
ADRC Referral
Palm Beach Country
Broward
Other
ADRC Referral Other
By
Monica Pascual
Kathy Kestler
Rejan Ferro
