Yellowstone Guardianship Application for Consideration
This application must be completed in full. The Council will not consider guardianship without a physician letter of incapacity and good faith effort to find family or interested parties to fill the role of guardian. If any required field is not complete, the application will not submit. Please call 406-259-3111 with any questions and we will refer you to the council leadership.
Please review our scope of service document at https://www.alliesinaging.org/guardianship-council prior to completing this application.
Date of referral
*
-
Month
-
Day
Year
Date
Referral made by
*
First Name
Last Name
Referrer's Title
*
Email of referrer
*
example@example.com
Phone Number of referrer
*
Please enter a valid phone number.
Format: (000) 000-0000.
Complete this checklist and send in with your application:
*
Fully Completed Application
Physician’s letter or statement of incapacity and need of guardianship (Please see below for necessary elements to be included in a letter or statement)
Court Visitor Recommendation (Please see below for necessary aspects of the court visitor role)
Good faith effort to find family or interested parties to be the guardian
Facility face sheet, most recent H&P or hospital summary, medication list
Full name of person needing guardianship
*
First Name
Last Name
Maiden name
Date of birth
*
-
Month
-
Day
Year
Date
Birthplace
Residence (name of facility)
*
Residence (facility address)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for referral
*
List top 5 diagnoses
*
Synopsis of individual's daily functioning:
*
Plans for long term care:
*
End of Life Plans
Does this person have a POLST?
*
Yes
No
Date of POLST
-
Month
-
Day
Year
Date
Does this person have a burial contract?
*
Yes
No
With whom is the burial contract located?
Medical Providers
Primary Physician
*
Phone Number of Primary Physician
*
Please enter a valid phone number.
Format: (000) 000-0000.
Other provider
Phone Number other provider
Please enter a valid phone number.
Format: (000) 000-0000.
Insurance
Medicare
Part A
Part B
Part D
Medicaid
*
Yes
No
Other Medical Insurance:
Income (List amounts known)
Does this person have personal assets greater than $2000?
*
Yes
No
Social Security
Social Security Disability
Social Security Income
Veteran Benefits
Other Retirement Income
Life Insurance
Personal Assets
Does this person have a Court Appointed Conservator?
*
Yes
No
Contact information for Court Appointed Conservator
Does this person have a Representative Payee?
*
Yes
No
Contact information for Representative Payee
Does this person have a Power of Attorney?
*
Yes
No
Name of Power of Attorney
First Name
Last Name
Phone of Power of Attorney
Please enter a valid phone number.
Format: (000) 000-0000.
Email of Power of Attorney
example@example.com
Financial status- Does this person have? (check all that apply)
*
Personal Property, e.g., house, car
Social Security
Medicare
Supplemental Security Income
Medicaid
The legal process for guardianship requires that we contact all known family and friends to see if they are willing to serve as guardians. List all known family, or interested parties with contact information, if known.
1. Name
First Name
Last Name
Address
Contact Information
Relationship
2. Name
First Name
Last Name
Address
Contact Information
Relationship
Any additional information you wish to share?
Physician of Record - To Write Statement for Court
Please provide the name and contact information of a physician who will complete the statement of incapacity for the court.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Physician's letter or statement should include:
· A description of the nature and degree of the present incapacity · Need for guardianship · Date of the last evaluation/examination -OR- * Complete and sign our Physician Statement of Incapacity and Need for Guardianship found at https://www.bigskyseniorservices.org/yellowstoneguardianship.html
Upload Physician's statement
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Court Visitor (please consider this role or ask someone else familiar with this case)
This individual may be a case worker, social worker or other professional willing to serve as a Court Visitor in this matter. The court will appoint as “visitor” a person who has experience or expertise in treating, evaluating, or caring for persons with the kind of disabling condition that is alleged to be the cause of the incapacity. The visitor interviews the person, visits their present place of abode, and submits a written letter to the court recommending whether the guardianship should be granted.
Name
First Name
Last Name
Address
Contact Information
Profession
You are welcome to present your referral at our monthly meeting, held the first Thursday of the month except for July, at 4:00pm. Contact Becky Wiehe at 406-259-3111.
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