Intake Sheet

Guardianship Assistance Program Client Questionnaire

Section I - Client

Names and contact information of all persons seeking Guardianship:

1. Name:______________________________________________ Date of Birth:___________
Relationship to incapacitated person_________________ SS#_____________________
Address: _______________________________________________________________________

Telephone Numbers: Cell: _________Day: _____________Evening: _________________
E-mail address: __________________________________________

2. Name:______________________________________________ Date of Birth:___________
Relationship to incapacitated person_________________ SS#_____________________
Address: _______________________________________________________________________

Telephone Numbers: Cell: _________Day: _____________Evening: _________________
E-mail address: __________________________________________

3. Name:______________________________________________ Date of Birth:___________
Relationship to incapacitated person_________________ SS#_____________________
Address: _______________________________________________________________________

Telephone Numbers: Cell: _________Day: _____________Evening: _________________
E-mail address: __________________________________________

Section II- Information about the person whom you are seeking the Guardianship

1. Name of person for whom you seek Guardianship:

_____________________________________________________________________

2. Age ___________, DOB _______________________Male____Female____

3. Social Security Number________________________________

4. Residence/Address:_____________________________________________________

5. Name and address of School (if applicable)___________________________________

6. Diagnosis_____________________________________________________________
Please provide the following information, if applicable, for this person. In most cases, the
person for whom you are seeking guardianship does not have certain assets or documents.

The court rules require details of assets be set forth in a Guardianship case.

1. Is there a Will? YES/NO

2. Is there a Power of Attorney? YES/NO

3. Are there any assets? If so, please list.(Also list bank accounts)
________________________________________________________________________

4. Are there any debts? Is so, please list.
________________________________________________________________________

5. Is there any income? If so, list the type and monthly amount.

_______________________________________________________________________

6. Is there a trust set up for this person? If so, has it been funded?

______________________________________________________________________

7. Is this person DDD eligible or receiving services from DDD?
_______________________________________________________________________

8. Is there an IEP that was prepared less than two years ago?
________________________________________________________________________

Section III- Information about next of kin

The Guardianship statute requires that all next of kin be given notice of the Guardianship Proceedings. Next of kin is defined as parents and siblings.

Please list the names and addresses of siblings and other parent (if that parent is not seeking guardianship):

1. Name:____________________________________________ Age:_________
Relationship ______________________________
Address: _______________________________________________________________

2. Name:____________________________________________ Age:_________
Relationship ______________________________
Address: ________________________________________________________________

3. Name:____________________________________________ Age:_________
Relationship ______________________________
Address: ________________________________________________________________

4. Name:____________________________________________ Age:_________
Relationship ______________________________
Address: ________________________________________________________________

Section IV-Physician

The Guardianship statute requires that all Guardianship Complaints be filed with EITHER :

1. The certifications of 2 physicians that we will provide to you.

2. Both physicians must be a medical doctor. Otherwise one of the certifications may be completed by a licensed psychologist. The Court will not allow a certification from a nurse practitioner or non-licensed psychologist.

3. Both physician’s evaluations must take place no more than 30 days prior to the filing of the Complaint.

IF THE PERSON IS DDD ELIGIBLE OR RECEIVING SERVICES FROM DDD:

1. One Physician Certification and;

2. A copy of an IEP prepared less than 2 years ago.

a. Name, address and fax number of Doctor 1

______________________________________________________________________________

b. Name, address and fax number of Doctor 2
______________________________________________________________________________
______________________________________________________________________________

Client’s Representation

I (we) certify that the information we have provided in this Questionnaire is truthful to the best of my/our knowledge.
_______________________________________________________ Date:___________________
_______________________________________________________ Date:___________________

PLEASE USE THIS PAGE TO WRITE ANY SPECIFIC QUESTIONS FOR THE ATTORNEY:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Guardianship Assistance Program (GAP)
105 High St., Mount Holly, NJ 08060
609-444-6653
609-751-9905 (fax)
Email: gapservices@comcast.net