Power of Attorney & Advance Directive Intake

About You

This questionnaire collects what we need to prepare an Oregon Financial Power of Attorney and/or an Oregon Advance Directive for Health Care. On the next step you'll choose which documents you want, and the form will ask only the questions for those documents.

Don't worry about total accuracy. Just do the best you can. Anything you're unsure about we'll go over together. If you have questions, please call our office at (541) 632-4313.

Your Legal Name

First Name *

Middle Name

Last Name *

Other Names You've Used maiden name, prior married names

Date of Birth

How to Reach You

Primary Phone *

Email *

Preferred Contact Method

Residence

Street Address

City

State

ZIP

County

Where do you currently live?

Family

Marital Status

Children names and cities — optional, but helpful if you may name them

Who Is Filling Out This Form?

Are you completing this form for yourself?

How did you hear about us?

Save & Resume Your progress is automatically saved to this browser as you go. You may also download your in-progress responses as a backup file and upload them later to continue on another device.

Which Documents Do You Want?

Select one or both. The questionnaire will adjust to ask only about the documents you choose.

Select at least one document to continue.

Financial Power of Attorney

Your "agent" (also called attorney-in-fact) is the person who will be able to act for you on financial matters.

Your Agent

Agent's Full Name *

Relationship to You

Phone

Email

City, State

Have you asked this person, and are they willing to serve?

More Than One Agent?

Do you want one agent, or two people serving at the same time (co-agents)?i

Backup (Successor) Agents

Who should serve if your agent can't or won't? List them in the order you want them to serve.

Full Name

Relationship

Phone

City, State

When It Takes Effect

When should your agent's authority begin?i

Scope of Authority

Special Powers

The law requires these powers to be granted specifically, because they can change who receives your property. If you're unsure, choose "Discuss" and we'll explain them at our meeting.

Should your agent be able to…	Your Choice
Make gifts of your money or property
Transfer assets into your existing revocable living trust
Create, amend, or revoke a trust for you
Change beneficiary designations (life insurance, retirement accounts, POD/TOD accounts)
Create or change joint ownership / survivorship rights
Plan for long-term care and Medicaid eligibility
Disclaim (refuse) an inheritance or gift on your behalf
Access the content of your email and electronic communications

Should your agent be able to…

Your Choice

Make gifts of your money or property

Transfer assets into your existing revocable living trust

Create, amend, or revoke a trust for you

Change beneficiary designations (life insurance, retirement accounts, POD/TOD accounts)

Create or change joint ownership / survivorship rights

Plan for long-term care and Medicaid eligibility

Disclaim (refuse) an inheritance or gift on your behalf

Access the content of your email and electronic communications

Oversight & Compensation

Should your agent be paid for their time?

Should your agent report to someone?i

If a court ever needs to appoint a conservator or guardian for you, whom do you nominate?

Your Property

Do you own real estate?

Do you own a business?

Anything else about your finances, family, or concerns your agent should know? optional

Advance Directive for Health Care

Your health care representative makes medical decisions for you only when you can't make them yourself.

Your Health Care Representative

Same person as my financial agent

Representative's Full Name *

Relationship to You

Phone

Email

City, State

Have you asked this person, and are they willing to serve?i

Alternate Representatives

Same people as my backup financial agents, in the same order

First Alternate

Full Name

Relationship to You

Phone

City, State

Second Alternate optional

Full Name

Relationship to You

Phone

City, State

Is anyone you named above your doctor or other health care provider, or an owner, operator, or employee of a care facility where you live or receive care?i

Health Care Instructions

Do you want to give specific instructions about life support and tube feeding, or leave those decisions to your representative?

Pain relief: should you receive medication to keep you comfortable, even if it might shorten your life?

What Matters Most to You

Optional, but this helps your representative and your doctors understand you. A few sentences is plenty.

What makes life meaningful to you? What would you want your care team to know?

Are there conditions or outcomes you would find unacceptable?

Where would you prefer to be at the end of life?

Religious or spiritual preferences optional

Any limits on what your representative may decide, or other instructions? optional

Organ Donation & Your Doctor

Organ and tissue donation

Do you have a POLST form on file with your doctor?i

Primary Care Provider

Clinic

Clinic Phone

Review & Submit

A summary of your responses appears below. Review it carefully, sign the affirmation, and click Submit.

Test Mode active. Clicking Submit will download a JSON archive of every answer instead of sending it. Switch TEST_MODE to false when ready to go live.

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Affirmation I understand that Crawley Law will rely on the information supplied above to prepare my documents. I also understand that submitting this form does not create an attorney-client relationship until an engagement agreement is signed. I affirm that the information I have provided is true and accurate to the best of my knowledge.

Signature (type full legal name) *

Date

Secure form — your information is encrypted in transit and protected.

Thank You

We've received your Power of Attorney & Advance Directive questionnaire.

We will review your responses and contact you about next steps. If we need any clarification, we will reach out by phone or email.

Reference ID:

Return to Crawley Law

POWER OF ATTORNEY & ADVANCE DIRECTIVE

About You

Which Documents Do You Want?

Financial Power of Attorney

Advance Directive for Health Care

First Alternate

Second Alternate optional

Existing Documents & Signing

Review & Submit

Thank You