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
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Name:____________________________________________
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Telephone: ____________________________
Fax: __________________________________
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Office Address: ____________________________________
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___________________________________________
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Email: _________________________________
Firm Web site: __________________________
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Firm Name: ________________________________________
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State Bar Membership(s): _________________
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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}.
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Wills { }
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Trusts { }
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Charitable Trusts { }
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Supplemental/Special Needs Trusts { }
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Living Trusts { }
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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:
______________________________________________________________________________________________
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Articles Published on Elder Law/Estate Planning (include name of publication, date published, title
of article(s)): _____________________________________________________________________________________
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Membership in Elder Law/Estate Planning Professional Organizations (name of organization, date of membership):
______________________________________________________________________________________________
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Presentations/Speeches to Disability Organizations (include title of organization, topic, dates):
______________________________________________________________________________________
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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.
