ADULT GUARDIANSHIP CLIENT INTAKE FORM

Proposed Guardian 1

First Name

Last Name

Proposed Guardian 2

First Name

Last Name

Proposed Guardian 1 Email

Proposed Guardian 2 Email

Proposed Guardian 1 Phone

(###)

###

####

Proposed Guardian 2 Phone

(###)

###

####

Proposed Guardian 1 Date of Birth

YYYY

Proposed Guardian 2 Date of Birth

YYYY

Proposed Guardian(s) Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Proposed Ward Full Name

Proposed Ward Date of Birth

YYYY

Proposed Ward Social Security Number

When and How Proposed Ward Came Into Care of Proposed Guardian(s)

If the proposed ward is not yet in your care, write "N/A."

Facts that Necessitate a Guardianship of the Proposed Ward

Please include all facts concering the current risks to the proposed ward, as well as any disabilities of the proposed ward.

Proposed Ward Property and Estimated Value

The approximate value and a description of the proposed ward's property, including any compensation, pension, insurance, or allowance to which he or she may be entitled.

Is there currently a guardian of the proposed ward in this state or any other state?

Is the Proposed Ward Married?

Yes

If the Proposed Ward is married, please provide spouse's name and contact information.

Is Proposed Guardian 1 a convicted felon?

If Proposed Guardian 1 is a convicted felon, please give more details about the conviction and its current status.

Is Proposed Guardian 2 a convicted felon?

If Proposed Guardian 2 is a convicted felon, please give more details about the conviction and its current status.

Is Proposed Guardian 1 the legal guardian of anyone else?

Is Proposed Guardian 2 the legal guardian of anyone else?

The names and addresses of others having knowledge about the person's disability.