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Search for:
ADEC Corporate Guardianship Referral
smeltzerj
2020-07-31T10:05:53-04:00
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.
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