Referral Form

Please use this form to submit all referrals to Corporate Guardians, Inc. Each referral will be reviewed upon receipt, and you will receive within 24 hours (usually less) a response from our referral staff. If you have questions about the referral process or the specific request, please email referrals@corporateguardians.org.

The information you provide in this form will be kept confidential and is stored securely.

Fields marked with * are required

Your First Name Your Last Name

Your Title/Position The county in which you work Your Phone Number Your Email Address

First Name of Proposed Service Recipient Last Name of Proposed Service Recipient

Phone Number of Proposed Service Recipient Email of Proposed Service recipient

Address of Proposed Service Recipient Street City

State Zip

If this address is a facility, what's the name of the facility? Type of Residential Setting: Contact Person at Residential Setting Phone Number for Residential Contact Email for Residential Contact Date of Birth of Proposed Service Recipient Social Security Number for Proposed Service Recipient Title 19/Medicaid Number (if applicable) Medicare Number (if applicable) Diagnosis Is the proposed ward a Veteran?

Social History (please provide a brief social history) Presenting Issues/Reason for Guardianship Explanation of Presenting Problems and Need for Guardianship (select as many as apply) Service Requested Service Requested Other Permanence (Is this a permanent guardianship? Successor? Temporary? something else?) To help us determine if we can accept this referral, what's the estimated time frame for when you expect the guardianship hearing to occur for this case? Please describe any safety concerns our staff should be aware of when making a visit. Payment of Fees Is the county willing to cover fees if the ward is unable?

Billing Contact First Name Billing Contact Last Name

Billing Contact Address Billing Contact Street Billing Contact City

Billing Contact State Billing Contact Zip

Billing Contact Phone Billing Contact Email Billing Contact Fax

Current Income Source (check all that apply) How much does the proposed service recipient receive for each of these income sources on a monthly basis? List all current assets for the proposed service recipient (Bank Accounts, Life Insurance, Investment Accounts, etc.). Include the names of financial institutions if known. List properties and vehicles for the proposed service recipient , including addresses and condition, if known. List any debt the proposed service recipient may owe, including mortgages or liens. Does the proposed service recipient have a current rep payee? Are there any other accounts, trusts, etc. that could be used to enrich the proposed service recipient's life? What is the contact information for the current rep payee? (Name, address, fax, phone, e-mail) List any pets the proposed service recipient may have.

Family/Interested Party 1 First Name Family/Interested Party 1 Last Name

Family/Interested Party 1 Phone

Family/Interested Party 1 Address Family/Interested Party 1 Street Family/Interested Party 1 City

Family/Interested Party 1 State Family/Interested Party 1 Zip

Interested Party 1 Relationship to Ward: Family/Interested Party 1 Relationship Dynamic

Family/Interested Party 2 First Name Family/Interested Party 2 Last Name

Family/Interested Party 2 Phone

Family/Interested Party 2 Address Family/Interested Party 2 City Family/Interested Party 2 State

Family/Interested Party 2 Street Family/Interested Party 2 Zip

Family/Interested Party 2 Relationship to Ward Family/Interested Party 2 Relationship Dynamic

Family/Interested Party 3 First Name Family/Interested Party 3 Last Name

Family/Interested Party 3 Phone

Family/Interested Party 3 Address Family/Interested Party 3 City Family/Interested Party 3 State

Family/Interested Party 3 Street Family/Interested Party 3 Zip

Family/Interested Party 3 Relationship to Ward Family/Interested Party 3 Relationship Dynamic

Professional Support 1 First Name Professional Support 1 Last Name

Professional Support 1 Agency Professional Support 1 Phone Professional Support 1 Email Professional Support 1 Fax

Professional Support 2 First Name Professional Support 2 Last Name

Professional Support 2 Agency Professional Support 2 Phone Professional Support 2 Email Professional Support 2 Fax

Professional Support 3 First Name Professional Support 3 Last Name

Professional Support 3 Agency Professional Support 3 Phone Professional Support 3 Email Professional Support 3 Fax