Intake Referral Form

GUARDIANSHIP INTAKE AND REFERRAL FORM

Thank you for requesting the services of this agency. We understand that not all of the information asked for on this form may be available at the time of the referral. Nevertheless, please fill it out as completely as possible since eligibility for the public guardianship program is mandated by Florida Statutes 744.2007 subsection (1) & (3). The information requested assists us in expediently making a determination.

To your knowledge, has the person being referred ever been convicted of a sexual offense?(Required)

Yes

No

Is the person being referred a U.S. citizen or lawful permanent resident (ie: Green Card holder)?(Required)

Yes

No

Ineligibility Notification

Based on the information provided, individuals with a history of sexual offense convictions are not eligible for services through this program. If you believe this is in error or have additional information, please contact our office at intake@aging-solutions.org or call 813-949-1888.

Ineligibility Notification

Our program is only available to U.S. citizens and lawful permanent residents. Based on the information provided, we are unable to proceed with this referral. If you have questions or additional documentation, please contact intake@aging-solutions.org or call 813-949-1888.

ELIGIBILITY CONSIDERATIONS FOR ACCEPTANCE

The following criteria are drawn from section 744, Florida Statutes, to determine a potential eligibility for Guardianship services:

1. The person alleging incapacity must be the petitioner for such or be willing to testify regarding their knowledge of the alleged incapacitated person by attending the adjudication hearing.
2. Advance Directives have not been located and family or friends, other persons are either unwilling or unable to assume guardianship, per the assessment of the referral source.
3. Asset and income information provided by the referral source shows the potential ward means of being able to support fee for service guardianship services.
4. Assessment that no alternative less restrictive than guardianship exists.

Please note that the acceptance of a potential Ward into the public guardianship program is made by the Office of the Public Guardian.

Please identify the county of the residential/current location of the alleged incapacitated individual (AKA Principal):(Required)

Who will be named as the petitioner for Guardianship

(i.e. social worker, nurse, administrator)

Petitioner Name(Required)

First Last

Petitioner Address(Required)

Street Address Address Line 2 City ZIP Code

Petitioner Email Address(Required)

Petitioner Phone(Required)

Who will sign the Representation Agreement for the Attorney who will represent the petitioner?

Representative Name(Required)

First Last

Representative Address(Required)

Street Address Address Line 2 City ZIP Code

Representative Email Address

Representative Phone(Required)

AIP or Principal

This information is absolutely essential; without it, acceptance into the program could be delayed.

AIP/Principal Name(Required)

First Last

Gender(Required)

Age(Required)

Please enter a number from 1 to 120.

Race(Required)

Marital Status(Required)

Religion Preference(Required)

Languages Spoken

(Hold CTRL or CMD for multiple)

Other Race (Please Specify)(Required)

Other Religion Prefrence (Please Specify)(Required)

Other Marital Status (Please Specify)(Required)

Other Language (Please Specify)(Required)

Social Security Number(Required)

Also Known As

Birth Place(Required)

Birth Date(Required)

AIP/Principal Current Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Does AIP/Principal own this home or any other home(Required)

AIP/Principal Phone(Required)

Length of time at this Address (Months)(Required)

Please enter a number from 1 to 12.

Length of time at this Address (Years)(Required)

Please enter a number from 0 to 100.

Previous Location(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Current/Previous Occupations(Required)

Anyone living with the Client?

Roommate (Please Specify)(Required)

Roommate Phone

Family/Significant Others (Please Upload additional sheet if needed):

Notice must be provided to next of kin regardless of their contact or interaction with the AIP/Principal, therefore, please list the names, addresses, phone numbers, and relationships of the living next of kin of the AIP/Principal, including the date of birth if the person is a minor. If married, this includes the spouse and all of his or her children: names, addresses, phone numbers, and extent of relationship.

Family Member Name(Required)

First Last

Family Member's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relation(Required)

Active Involvement(Required)

Family Member's Phone(Required)

Add Additional Family Member

2nd Family Member Name(Required)

First Last

2nd Family Member's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

2nd Member's Relation(Required)

2nd Member's Active Involvement(Required)

2nd Family Member's Phone(Required)

Why does this AIP/Principal need a guardian? (Please be specific, thorough, and convincing)(Required)

Attending Physician

Prefix First Last Suffix

Attending Physician Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Attending Physician Phone

Dentist

First Last

Dentist Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Dentist Phone

Diagnosis Affecting Mental Capacity(Required)

All Other Medical Diagnoses

Allergies

Medical History(Required)

Mental status/Level of Functioning(Required)

(including ambulation and ADL’s – such as grooming, bathing, eating, dressing, etc.)

Psychological Testing(Required)

(include type of exam and scores)

Alternatives to Guardian:

All Advance Directives as defined in FS 765 must be listed below.

Representative Payee Under 42 U.S.C. s 1007(Required)

Representative Payee Name(Required)

First Last

Representative Payee Phone(Required)

Existing Do Not Resuscitate order as defined in FS 401.45(3)(Required)

Name(Required)

First Last

Phone(Required)

Living Will Under FS 765.301(Required)

Does the Living Will designate an individual to act(Required)

(please attach a copy, with the name and number of the individual)

Living Will File

Accepted file types: pdf, Max. file size: 5 MB.

Health Care Surrogate Under FS 765.201(Required)

Name(Required)

First Last

Phone(Required)

Health Care Proxy Under FS 765.401(Required)

Name(Required)

First Last

Phone(Required)

Durable Power of Attorney as defined in FS 709(Required)

Name(Required)

First Last

Phone(Required)

A Trust instrument as defined in 736.0103 (please attach a copy if applicable)(Required)

Untitled(Required)

Trust instrument File

Accepted file types: pdf, Max. file size: 5 MB.

Anatomical Gifts Under FS 765. 510(Required)

Assets/Property

Personal (accounts, stocks, furniture, Real (Land, buildings, mobile homes, jewelry, etc.)

Monthly Income

SS

SSI

OSS

VA

Pension/Annuity

Dividend/Interest

Other Income

Medicare #

Medicaid #

Veterans #

Other Insurance

Is this referral being submitted by a facility or agency representative?

For Facilities Only

Name(Required)

First Last

Date(Required)

Category(Required)

Other Category (Please specify)(Required)

Name of Agency(Required)

Agency Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code