Guardianship Administration Intake

Welcome. This short intake helps us prepare for your guardianship consultation. Fill in what you can - fields can be left blank.

Step 1 of 4

25%

URL

This field is for validation purposes and should be left unchanged.

Save your progress as you go. This form is long. Use the "Save and Continue Later" link at the bottom of the form to save periodically, especially before stepping away or closing your browser. When you save, you will receive an email with a link to resume right where you left off.

Welcome. This short intake helps us prepare for your guardianship consultation. Fill in what you can - fields can be left blank.

Type of Guardianship Requested (Check all that apply)

Type of Guardianship

Guardian of the Person

Guardian of the Estate

Plenary (Full)

Limited

Emergency / Temporary

Standby

PA County (Court of Common Pleas)

Orphans' Court Docket # (if known)

About the Person Who Needs a Guardian

Full legal name(Required)

Date of birth

MM slash DD slash YYYY

Age

Last 4 of SSN

Preferred language

Veteran?

Yes

Current address (or facility name & address)

Street Address Address Line 2 City State ZIP Code

Type of residence (home, AL, SNF, etc.)

Phone where IP can be reached

About You (The Proposed Guardian / Petitioner)

Your full name(Required)

Your relationship to the person

Your address

Street Address Address Line 2 City State ZIP Code

Your phone

Your email

Your date of birth

MM slash DD slash YYYY

Co-Guardian or Successor Guardian (Optional)

Co-guardian name

Co-guardian relationship to IP

Successor guardian name

Successor guardian relationship to IP

Medical & Capacity

Primary diagnosis or condition

Other conditions (if any)

Treating physician

Hospital / care facility

Can the person communicate their wishes?

Yes

Has the person been evaluated by a physician or psychologist?

Yes

Is there an existing capacity / clinical evaluation report?

Yes

Is the person currently receiving therapy or rehabilitation?

Yes

Has the person previously been adjudicated incapacitated?

Yes

Family Members & Interested Parties

PA law requires notice to certain family members. List spouse, parents, adult children, and siblings - add more rows as needed.

Family Members & Interested Parties

Name

Relationship

Address

Phone / Email

Existing Legal Documents (Check what exists; date if known)

Last Will & Testament - Exists?

Yes

Last Will & Testament - Date

MM slash DD slash YYYY

Last Will & Testament - Where kept

Durable Power of Attorney (financial) - Exists?

Yes

Durable Power of Attorney (financial) - Date

MM slash DD slash YYYY

Durable Power of Attorney (financial) - Where kept

Healthcare Power of Attorney - Exists?

Yes

Healthcare Power of Attorney - Date

MM slash DD slash YYYY

Healthcare Power of Attorney - Where kept

Living Will / Advance Directive - Exists?

Yes

Living Will / Advance Directive - Date

MM slash DD slash YYYY

Living Will / Advance Directive - Where kept

Revocable or Irrevocable Trust - Exists?

Yes

Revocable or Irrevocable Trust - Date

MM slash DD slash YYYY

Revocable or Irrevocable Trust - Where kept

Prior Guardianship Order - Exists?

Yes

Prior Guardianship Order - Date

MM slash DD slash YYYY

Prior Guardianship Order - Where kept

Assets - Quick Summary (Estimates are fine)

List approximate totals - no need to look up exact balances. We will gather details together.

Real estate (home & other property) - Approx. value $

Bank / checking / savings accounts - Approx. value $

Investments, IRAs, 401(k), annuities - Approx. value $

Life insurance (cash value) - Approx. value $

Vehicles & personal property - Approx. value $

Business interests - Approx. value $

Other assets - Approx. value $

Notes about assets (joint owners, beneficiaries, anything unusual)

Monthly Income (rough monthly figures)

Income - Social Security (SSI / SSDI)

Income - Pension / retirement

Income - VA benefits

Income - Rental income

Income - Investment / dividends

Income - Other income

Total monthly income $

Monthly Expenses (rough monthly figures)

Expense - Housing / facility / room & board

Expense - Utilities

Expense - Food / groceries

Expense - Medical / prescriptions

Expense - Insurance premiums

Expense - Other expenses

Total monthly expenses $

Healthcare & Benefits

Medicare

Yes

Medicaid / Medical Assistance

Yes

Private health insurance

Yes

Community HealthChoices (CHC) waiver

Yes

Designated healthcare proxy / HCPOA

Yes

DNR / advance directive in place

Yes

Hospice or palliative care

Yes

On a waiting list for services or facility

Yes

Current health insurance provider(s)

Your goals, concerns, or anything else we should know

How did you hear about us?

Referral Source

KDKA Radio

IN Magazine

Friend

Family

Financial advisor

Seminar / webinar

Web search

Other

If 'Other', please describe

Guardianship Administration Intake

Type of Guardianship Requested (Check all that apply)

About the Person Who Needs a Guardian

About You (The Proposed Guardian / Petitioner)

Co-Guardian or Successor Guardian (Optional)

Medical & Capacity

Family Members & Interested Parties

Existing Legal Documents (Check what exists; date if known)

Assets - Quick Summary (Estimates are fine)

Monthly Income (rough monthly figures)

Monthly Expenses (rough monthly figures)

Healthcare & Benefits

How did you hear about us?

Elder Law and Estate Planning Attorneys