Guardianship Intake Form (Page 3 of 3) in pdf

Guardianship Intake Form Page 3

Are you seeking guardianship of the Ward’s person only, the Ward’s estate only or

the Ward’s person and estate?

_________________________________________________

Do you expect the proposed Ward to contest the guardianship?

____________________

Is this an emergency requiring pursuit of a temporary guardianship?

________________

What is the name, address and phone number of the proposed Ward’s psychiatrist or

physician?

___________________________________________________________________

__________________

When did the proposed Ward last see this physician?

_____________________________

When will the proposed Ward next see this physician?

___________________________

Does the proposed Ward’s psychiatrist or physician support the Guardianship?

________

If the proposed Ward takes antipsychotic medication or may be prescribed

antipsychotic medication in the future, do you expect that the Ward’s psychiatrist or

physician will remain the same next year?

_________________________________________________

What types of health insurance, if any, does the proposed Ward have?

_______________

___________________________________________________________________

_____

Has the proposed Ward executed a Health Care Proxy (living Will) or a Will?

________

Has the proposed Ward named anyone as future Guardian?

_______________________

What is the proposed Ward’s diagnosis?

______________________________________

Has the proposed Ward ever been psychiatrically hospitalized?

____________________

Guardianship Intake Form Page 3