Guardianship Svcs Referral - AUTOMATED FORM



Date: FORMTEXT ?????Person making referral: FORMTEXT ?????Phone: FORMTEXT ?????Agency/position: FORMTEXT ?????Is person receiving any other LSS Service? If yes, what? FORMTEXT ?????[LSS use only]Name of County: FORMTEXT ?????Court File # (if available): FORMTEXT ?????County approval for payment: FORMCHECKBOX No FORMCHECKBOX Yes, by whom? FORMTEXT ?????Referral for: FORMCHECKBOX Guardianship FORMCHECKBOX Conservatorship FORMCHECKBOX Both FORMCHECKBOX General FORMCHECKBOX EmergencyCurrent situation/reason for referral:Impairment/Diagnosis causing lack of capacity or understanding to make or communicate responsible decisions regarding personal or financial affairs: FORMTEXT ?????Specific behavior showing inability to meet medical, nutrition, shelter, clothing, safety and/or financial needs: FORMTEXT ?????Attach Supporting DocumentationBilling Information:Party responsible for payment to LSS: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Relationship: FORMTEXT ?????Current Support Team:County Case Manager PhoneFaxEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????County Financial Worker PhoneFaxEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Day Program/Main ContactAddress FORMTEXT ????? FORMTEXT ?????Day Program PhoneFaxEmail FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Client Data:Name: (last) (first) (middle) FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Permanent Address (house number, street, apartment, city, zip): FORMTEXT ????? Current Address if different from permanent:Facility Name if applicableAddress (number, street, city)Admission Date FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Date of birthGenderMarital statusPlace of Birth (City, State)Client Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Primary PhysicianClinicAddress (number, street, city)Physician Phone FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Medicare # Medical Assistance #Other InsuranceEffective Dates of Insurance FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Code Status EthnicityReligion/Faith FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Mothers Maiden NameParents First and Last NamesSocial Security Number FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Interested Persons: (Name, Address, Phone, Email) FORMTEXT ?????Spouse/Partner FORMTEXT ?????Health Care Agent FORMTEXT ?????Caregiver (if other than Spouse/Partner) FORMTEXT ?????Parent(s) FORMTEXT ?????Child FORMTEXT ?????Child FORMTEXT ?????Legal Representative FORMTEXT ?????Financial POAOther Contacts: (Name, Address, Phone, Email) FORMTEXT ????? Attorney FORMTEXT ?????Home Health Care FORMTEXT ?????Mental Health Professional FORMTEXT ?????DentistIncome:Social Security: FORMTEXT ?????SSI: FORMTEXT ?????Pension Co. Name: FORMTEXT ?????Pension Amount: FORMTEXT ?????Pension Co Phone: FORMTEXT ?????Fax: FORMTEXT ?????Email: FORMTEXT ?????Veteran Benefits: FORMTEXT ?????Amount: FORMTEXT ?????Other Income 1: FORMTEXT ?????Other Income 2: FORMTEXT ?????Assets (Banking or Investments):Real estate address: FORMTEXT ?????Estimated Value: FORMTEXT ?????Account Name: FORMTEXT ?????Type of Account : FORMTEXT ?????Address: FORMTEXT ?????Phone & Fax: FORMTEXT ?????Account #: FORMTEXT ?????Value: FORMTEXT ?????Account Name: FORMTEXT ?????Type of Account : FORMTEXT ????? Address: FORMTEXT ????? Phone & Fax: FORMTEXT ?????Account #: FORMTEXT ????? Value: FORMTEXT ?????Account Name: FORMTEXT ?????Type of Account : FORMTEXT ????? Address: FORMTEXT ????? Phone & Fax: FORMTEXT ?????Account #: FORMTEXT ????? Value: FORMTEXT ?????Other:Vehicle Make: FORMTEXT ?????Year FORMTEXT ?????Value FORMTEXT ?????Funeral/Prepaid Burial – Name: FORMTEXT ?????Policy #: FORMTEXT ?????Value FORMTEXT ?????Safety Deposit Box: FORMTEXT ?????Where: FORMTEXT ?????Keys: FORMTEXT ?????Debts/Liens/Judgments: FORMTEXT ?????Amount: FORMTEXT ?????Pets: FORMTEXT ?????Type” FORMTEXT ?????#: FORMTEXT ?????### ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download