Guardianship Questionnaire

CONFIDENTIAL GUARDIANSHIP QUESTIONNAIRE

The following questionnaire is designed to expedite our efforts in representing you in the Article 81 Guardianship proceeding. Whether you are a new or an established client, we have found this questionnaire extremely helpful, and therefore ask you to complete it prior to your appointment. Those questions that do not apply to your family or financial situation may simply be left blank. Please feel free to attach additional pages where space is needed or to provide other information you feel is relevant. There is a space below to upload any of your documents securely. Our site uses SSL Encryption to protect your data.

NOTE: IF YOU NEED TO COME BACK TO COMPLETE THE QUESTIONNAIRE, YOU CAN HIT “SAVE AND CONTINUE” AT THE BOTTOM OF THIS PAGE. YOU WILL RECEIVE AN EMAIL WITH A LINK TO CONTINUE/COMPLETE THE QUESTIONNAIRE.

GUARDIANSHIP TERMINOLOGY

Guardianship proceedings under New York State law require a basic understanding of certain terminology. The legal definition of the person for whom you are requesting a Guardian is the Alleged Incapacitated Person (AIP); the person who petitions the Court is the Petitioner; and the person whom the Court appoints is the Guardian of Personal Needs and/or Property Management. The Petitioner and the Guardian may be the same person, or different persons. One person may be the Guardian for both Personal Needs and Property Management, or there may be a separate Guardian for each.

This field is hidden when viewing the form

Today's Date:(Required)

Name(Required)

First Middle Last

Address(Required)

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

Phone(Required)

Phone (Other)

Email(Required)

Name of Alleged Incapacitated Person (AIP)

Address of AIP

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

Relationship, if any, of AIP to you

AIP's Date of Birth

Will you propose a change of residence for the AIP?

Yes

Do you believe the AIP will oppose appointment of a Guardian?

Yes

If Yes, why do you believe a change of residence may be necessary?

If you are not interested in being Guardian, provide the name(s) of proposed Guardians

Name

Address

Phone Number

Relation

Please use the + button to the right to add additional proposed Guardians.

Would any of the proposed Guardians have difficulty obtaining a bond?

Yes

A bond is a required insurance policy which may be required by the Court ensuring that the Guardian properly discharge their duties.

Why do you believe the AIP needs a Guardian to make financial decisions?

Why do you believe the AIP needs a Guardian for personal needs?

Why do you believe proposed Guardian(s) is/are suitable?

Are there any emergencies requiring immediate action? (Check all that apply)

Health Hazards

Fire Hazards

Utility shut offs

Foreclosure or eviction

Lapse in health insurance

Lapse in home/renter insurance

Lapse in car insurance

Functional Limitations of AIP

Please indicate whether the AIP can or cannot perform the following by themselves.

Walking

Eating

Dressing

Grooming

Toileting

Transfer from bed to chair or toilet

Housekeeping

Making investment decisions

Dealing with pension, retirement, IRA, KEOGH/SEP and other similar plans

Making decisions regarding social environment and social activities

Leaving residence by self without getting lost

Applying for Government entitlements

Consenting to or refusing routine medical treatment

Shopping

Reading Mail

Answering the phone

Making bank deposits

Writing checks

Driving a car or using public transportation

Please provide any necessary detail on your above answers

What functions can the AIP currently perform?

Have there been any unusual or potentially dangerous behaviors? Describe in detail.

Has the AIP done anything with their possessions that you disapprove of?

Describe the AIP's current gift-giving patterns. Who are the beneficiaries and what are their relationships, if any, to the AIP?

Is the AIP currently employed?

Yes

If Yes, what is the AIP's occupation

Name of employer

Address of employer

Does the AIP have business responsibilities?

Yes

If Yes, please describe

Does the AIP have responsibilities for others?

Yes

If Yes, please describe

AIP Health Information

Does the AIP have any medical or psychiatric problems and diagnoses?

Yes

If Yes, please provide detail

List any health care providers

Name

Specialty

Phone Number

Please use the + to the right to add additional health care providers

Medications the AIP is currently prescribed

Medication

Dose

Pharmacy

Please use the + to the right to add additional medications

Recent hospitalizations

Hospital

Date

Length of Stay

Please use the + to the right to add additional dates

How is payment made for medical bills? (check all that apply)

Medicare

Medicare insurance supplement

Private insurance

Medicaid

Cash

Does the AIP have a Health Care Proxy?

Yes

If Yes, please provide the name of the Proxy and date signed

Does the AIP have a Living Will?

Yes

If Yes, please provide the date signed

Does the AIP have a Do Not Resuscitate Order (DNR)?

Yes

Should competency of the AIP at the time of signing any of the above be questioned?

Yes

Relatives of AIP

Please list spouse, parents, adult siblings, adult children or other close relatives of the AIP.

Relative

Name

Relation

Addresss

Please use the + button to the right to add additional relatives.

Other Interested Parties

Please other interested parties.

Person(s) with whom the AIP resides

Name

Address

Phone Number