Guardianship Intake Form (Page 2 of 3) in pdf

Are any of the next of kin currently in the United States armed service?

______________

Is the proposed Ward currently taking antipsychotic medication?

___________________

If not, has the proposed Ward’s physician indicated that antipsychotic medication

may be prescribed within the next fifteen months?

__________________________________

Are you seeking authority to admit or commit the proposed Ward to a mental health

facility?

Please list the name(s) and address(es) of the Petitioners for Guardianship who

would sign the Petition itself. (Only one Petitioner is required if he or she is a parent

of the proposed Ward; otherwise two Petitioners are required.)

___________________________________________________________________

__________

What is/are the relationship(s) between the Petitioner(s) and the proposed Ward?

___________________________________________________________________

_____

Name(s) and address(es) of the proposed Guardian(s)?

___________________________

___________________________________________________________________

_____

If the proposed Guardian(s) live out of state, who would be their in-state agent?

___________________________________________________________________

_____

Is the proposed Ward entitled to any benefits through the United States Veterans

Administration? ____________

Does the proposed Ward own any real estate? If so, what is the estimated value of

the real estate?

______________________________________________________________

What is the value of the proposed Ward’s personal estate (i.e. all assets excluding

real estate)?

_________________________________________________________________

___________________________________________________________________

____

Is the proposed Ward receiving any public benefits such as Supplemental Security

Income, Social Security Disability Income, etc.?

_______________________________

Guardianship Intake Form Page 2