Guardianship and Conservatorship Questionnaire

Adult Guardianship and Conservatorship

Your full name (First, Middle Initial, Last):

Any other name(s) by which you have been known:

Your physical address:

Street Address Address Line 2 City State ZIP Code

Your mailing address (if different from above):

Street Address Address Line 2 City State ZIP Code

Your primary phone number:

Your alternate phone number (if any):

Your email address:

Full name of Proposed Ward (First, Middle Initial, Last):

(The Proposed Ward is the person over whom you are seeking guardianship and/or conservatorship)

What is the Proposed Ward's Date of Birth?

What is your relationship to the Proposed Ward?

Proposed Ward's current physical address:

Street Address Address Line 2 City State ZIP Code

What County does the Proposed Ward reside in?

Proposed Ward's current mailing address (if different from above):

Street Address Address Line 2 City State ZIP Code

Proposed Ward's primary phone number:

Proposed Ward's alternate phone number (if any):

Proposed Ward's email address:

Identify all living children or parents of the Proposed Ward:

Full Name

Address (physical and mailing if applicable)

Telephone (and alt. tel. # if applicable)

Relationship to Proposed Ward

(To add more entries, select the plus sign to the right of the last column)

Please identify any person who has lived with the Proposed Ward for more than six (6) months in the last one (1) year:

Full Name

Address (physical and mailing, if applicable)

Telephone (and alt. tel. # if applicable)

Relationship to Proposed Ward

(To add more entries, select the plus sign to the right of the last column)

Please select which of the following documents the Proposed Ward has executed:

Medical Power of Attorney / Power of Attorney for Health Care

General Power of Attorney

Health Care Directive / Advance Directive (aka “Living Will”)

Last Will and Testament

Trust Agreement

Designated Beneficiary Agreement

(If any of the boxes are selected, please provide a copy to The Ala Firm).

Does the Proposed Ward have any other acting legal representative?

(For example, a representative payee, a trustee, a custodian of a trust, etc. not otherwise identified above)

Who?

Full Name

Address (both physical and mailing if applicable)

Telephone (and alt. tel. # if applicable)

Type of Representative

(To add more entries, select the plus sign to the right of the last column)

Name of Proposed Ward's current treating/primary physician:

If possible, please provide a letter from the treating physician supporting the request for guardianship and/or conservatorship.

Address of current treating/primary physician:

Street Address Address Line 2 City State ZIP Code

Phone number of current treating/primary physician:

Identify any other treating physicians/caregivers:

Name

Provider Type

Address

Phone

(To add more entries, select the plus sign to the right of the last column)

Are you requesting Guardianship, Conservatorship, or Both?

Has a Guardian or Conservator been appointed for the Proposed Ward in the past?

Do you personally wish to be the Guardian for the Proposed Ward?

Full name of proposed Guardian (First, Middle Initial, Last)

Address of Proposed Guardian:

Street Address Address Line 2 City State ZIP Code

Phone number of proposed Guardian:

Alternate phone number of proposed Guardian (if any):

Email address of proposed Guardian:

If your request for Guardianship is granted, will the Proposed Ward's address change?

(For example, select “Yes” if you intend to relocate the Proposed Ward to an assisted living facility, nursing home, or other new living situation).

New physical address for Proposed Ward (if Guardianship is approved):

Street Address Address Line 2 City State ZIP Code

Please describe the Proposed Ward's disabilities or impairments (physical and/or mental) which support your request for guardianship:

Do you wish to personally be the Conservator for the Proposed Ward?

Full name of proposed Conservator (First, Middle Initial, Last)

Address of proposed Conservator:

Street Address Address Line 2 City State ZIP Code

Phone number of proposed Conservator:

Alternate phone number of proposed Conservator (if any):

Email address of proposed Conservator:

Please describe the Proposed Ward's disabilities or impairments (physical and/or mental) which support your request for conservatorship:

List all known assets of the Proposed Ward:

Description of Asset

Estimated Value

This is required on the petition to be filed with the Court. For example, bank accounts, property, pensions, insurance, retirement accounts.

List all known income of the Proposed Ward:

Description of Income

Estimated Amount

This is required on the petition to be filed with the Court. For example, social security, pension, insurance, annuities, etc.