Guardianship Intake Form (Page 2 of 2) in pdf

Guardianship Intake Form Page 2

Siblings (Indicate brother/sister): ___________________________________________________

______________________________________________________________________________

Other Family (if none of above, indicate relationship): _________________________________

______________________________________________________________________________

Please check if any of the following apply:

_____ Alleged disabled person likely requires 24 assistance at home

_____ Alleged disabled person likely requires long-term nursing home placement

_____ Alleged disabled person needs Medicaid assistance

_____ Alleged disabled person being cared for currently by family members

_____ Family members are expected to contest hearing

_____ Alleged disabled person expected to contest hearing

_____ Money may have been withdrawn recently without alleged disabled person’s consents

_____ Alleged disabled person holds money in joint tenant accounts with other persons

_____ Alleged disabled person has signed Will and/or Trust

_____ Guardianship has been filed in another state or county

Signed: ____________________________________________

Date:__________________

Guardianship Intake Form Page 2