Please Print and return this form to The NAMI Legal Center, NAMI, 3803 N. Fairfax Dr., Ste. 100, Arlington, VA 22203.

Date: ___________________________

Elder Law/Estate Planning


Name:____________________________________________

 

Telephone: ____________________________

Fax: __________________________________

Office Address: ____________________________________

___________________________________________

___________________________________________

Email: _________________________________

Firm Web site: __________________________

Firm Name: ________________________________________

State Bar Membership(s): _________________

_______________________________________


NAMI is particularly interested in your experience in providing legal services to family members and people with mental illness and/or other disabilities. Please include information on the attached form or attach a curriculum vitae that demonstrates your specific experience in this area.

Please indicate the areas of Elder Law/Estate Planning for which you would like to receive client referrals {indicate in the brackets the number of years you have practiced in these areas}.

Wills { }

Trusts { }

Charitable Trusts { }

Supplemental/Special Needs Trusts { }

Living Trusts { }

Indicate your hourly rate and retainer fee requirements:

Hourly Rate: _______________________ Retainer Fee Requirements: _________________________

I am now and will continue to be covered by professional liability insurance in the amount of $200,000 per occurrence and $500,000 aggregate. I understand that I am responsible for maintaining professional liability insurance coverage as a condition of participating on NAMI’s Lawyer Referral Panel. Please provide the following information related to the insurance policy:

Ins. Company _____________________ Amt. of Coverage __________ Expiration Date ___________

I hereby certify that at the time of this application, I am not subject to any disciplinary action related to my license to practice law. I agree to inform NAMI if at any time there is any action taken against my license to practice law in any of the states in which I am licensed to provide professional services.

I apply for registration on the NAMI Lawyer Referral Panel. I certify that I will abide by the rules related to participating on the lawyer referral panel.

Date: _________________________ Signature: _____________________________________________

 

 

Education:

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________


Articles Published on Elder Law/Estate Planning (include name of publication, date published, title

of article(s)): _____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Membership in Elder Law/Estate Planning Professional Organizations (name of organization, date of membership):

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Presentations/Speeches to Disability Organizations (include title of organization, topic, dates):

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

If you know of other lawyers who specialize in the area of Elder Law/Estate Planning and may be interested in participating on our Lawyer Referral Panel, please include the name and contact information below.

 

Name: ____________________________________ Name: ___________________________________

Contact Information: _________________________ Contact Information: ________________________

Thank you for your interest in NAMI, our members and others seeking legal representation.