Guardianship Intake Form Petitioner/proposed Guardian
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4GUARDIANSHIP INTAKE FORM
Petitioner/Proposed Guardian
Name
______________________________________
Address - Residence
Address - Mailing (if different)
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
Telephone
Home (_____) _______________
Work (_____) _______________
Date of Birth
_______________________
Place of Birth
______________________
Social Security No.
______-____-______
U.S. Citizen?
Yes
No
Marital Status
____________
Name of Spouse, if married
_____________________
Length of residence in county where guardianship will be filed:
_____________________
Are you currently serving as guardian for any other ward(s)?
Yes
No
If yes, please indicate name of ward(s), case number(s), and location(s):
______________________________________________________________________
Do you have any physical disabilities?
Yes
No
If yes, provide a brief description of the disabilities, and whether said disabilities will
affect your ability to serve as guardian:
______________________________________________________________________
Have you ever been treated for:
Mental Condition Yes
No
If yes, when and where:
_______________
Alcohol Yes
No
If yes, when and where:
_______________
Drugs Yes
No
If yes, when and where:
_______________
Other Yes
No
If yes, when and where:
_______________
Name of physician(s) or professional(s) involved:
__________________________________
Have you ever been judicially determined to have committed abuse or
Yes
No
neglect against a child as defined by the Florida Statutes?
Have you ever been the subject of a confirmed report of abuse,
Yes
No
neglect, or exploitation?
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