GUARDIANSHIP & CONSERVATOR QUESTIONNAIRE
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1 GUARDIANSHIP & CONSERVATOR QUESTIONNAIRE NAME OF INCAPACITATED RESIDENCE ADDRESS: COUNTY/CITY/ZIP: TELEPHONE #: DOB: AGE: SSN: MARITAL STATUS: PRESENT LOCATION (incl. room & floor for hosp): Height (apx) Weight (apx) Hair color Eye color Race (For State police form SP-237 reporting info for incapacitated adults) RELATIVES OF INCAPACITATED PERSON: Please list ALL of the incapacitated person's living relatives in this order: spouse, adult children, parents, and adult siblings or, if no such relatives are known, please list THREE other known living relatives, including step-children. Name/Age Relation Full Mailing Address & Telephone Number 1
2 DIAGNOSIS MEDICAL INFORMATION Current Physician: Date last visit: Address/Phone: Psychiatrist/Neurologist: Date last visit: Address/Phone: Hospital: Date of Admission: Hospital Social Worker: Phone: Nursing/Adult Home: Phone: Address: Contact Name: INCOME Social Security $ /month Type: Retirement $ /month Source: Interest Other $ /month Source: $ /month Source: ASSETS Real Estate Location: Current Tax Assessed value $ Taxes due? How Held/Ownership? Mortgage/Liens? 2
3 ASSETS (Real Estate continued): ThompsonMcMullan, P.C. Insurance carrier and policy number: If the real estate is occupied, please explain Motor Vehicles Make/Model Year Value Make/Model Year Value Any other valuable personal property: Describe Value Bank Accounts Life Insurance KIND whole/term OWNER BENEFICIARY LIFE FACE AMOUNT CASH VALUE HEALTH INSURANCE Medicare A B ID # Secondary Supplement ID# Premium $ Medicare D: ID# Premium $ Medicaid ID # City/County Eligibility Date: Worker 3
4 PROPOSED GUARDIAN: EVER BEEN REFUSED BOND? PROPOSED CONSERVATOR (if different than Guardian): EVER BEEN REFUSED BOND? (to serve as conservator for an individual whose estate including real property OR annual income exceeds $15, you must be able to qualify for a fiduciary surety bond and a credit report will be requested from the surety company when applying for the bond) PETITIONER / PERSON OR ENTITY BRINGING PETITION: EVER BEEN REFUSED BOND? 4
5 CURRENT AGENT UNDER POWER OF ATTORNEY OR MEDICAL DIRECTIVE (ENCLOSE COPY) DATE OF POA: STATUS OF POA (CURRENT, REVOKED, RESIGNED, ETC.) PERSON COMPLETING THIS FORM: RELATION to incapacitated person: HOW WERE YOU REFERRED TO US? ADDITIONAL COMMENTS: MENTAL HEALTH OPTIONS FOR GUARDIANSHIP PETITION: Va. Code & : Ask for authority for guardian to consent to the admission of respondent to a facility & consent to medical and psychiatric treatment, including administration of anti-psychotic medications and administration of electro-convulsive therapy YES NO Please note that courthouses do not permit cell phones or similar devices (or any weapon) inside their buildings. Please do not bring such items to the hearing or qualification or you may not be admitted in the court. PLEASE RETURN COMPLETED FORM TO MARY BETH RAWLS, THOMPSONMCMULLAN, PC, 100 SHOCKOE SLIP, RICHMOND, VA OR VIA FAX OR VIA MBRAWLS@T- MLAW.COM FN:T:\Majettes\DASHBOARDS\Questionnaires\Guardianship Data Qst 2013.Doc 8/12/2013 5
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