ADEC Corporate Guardianship Referral – ADEC

Skip to content

Facebook Instagram Tiktok LinkedIn Spotify YouTube

574.848.7451|info@adecinc.com

BLOG
ENTERPRISE
SHOP
DONATE
GET INVOLVED
PROGRAMS
EMPLOYMENT
RESOURCES
Search for:

BLOG
ENTERPRISE
SHOP
DONATE
GET INVOLVED
PROGRAMS
EMPLOYMENT
RESOURCES
Search for:

BLOG
ENTERPRISE
SHOP
DONATE
GET INVOLVED
PROGRAMS
EMPLOYMENT
RESOURCES

ADEC Corporate Guardianship Referral2024-07-09T14:48:37-04:00

ADEC Corporate Guardianship Referral

General information
Immediate need for guardianship?*
- Yes
- No
Client name*
Nickname(s)
Date of birth*
Address*
Phone number*
Email address*
Gender*
- Male
- Female
Race (For guardianship registry)*
Hispanic*
- Yes
- No
Identifying marks
Hair color
Eye color
Height
Weight
Religious preference
Is this person on a Medicaid Waiver?*
- Yes, CIH
- Yes, FSW
- No
Type of residence
- Group home
- Supported living
- Lives with family
- Own home
- Apartment
- Other
Diagnoses*
Primary care physician
Physician phone
Dentist
Specialist
Does the person have a payee?*
- Yes
- No
Payee name
Is the person in any other ADEC programs?
- Supported living
- Group living
- Day services
- Community employment
- Family services/Therapies
Residential Provider information
Name of provider
Contact person
Address
Phone
Email
Day programming
Name of provider
Contact person
Address
Phone
Schedule
Other contacts
Case manager name
Case manager phone number
Case manager email
Behaviorist name
Behaviorist phone number
Behaviorist email
Family member name
Family member phone number
Family member email address
Other contact
Is the person imminently vulnerable to exploitation from others?*
- Yes
- No
Referred by
Referrer Name*
Referrer Organization and title*
Referrer Address
Referrer Phone number*
Referrer Email address*
Discuss reason for referral. Be as specific as possible.*
With this referral, please submit an ISP, diagnostic evaluations, or other information you feel would be helpful to determine eligibility for guardianship.

Δ

ADEC ADMINISTRATION BUILDING
1671 West Vistula Street
BRISTOL, INDIANA

574.848.7451 – [email protected]
OFFICE HOURS: Monday – Friday, 8 AM – 4:30 PM

bqdxaFMa_400x400

candid-seal-platinum-2023

Page load link