Guardianship Questionnaire

This simple intake questionnaire will help us prepare for our first meeting.

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Please provide the following information about your child.

Full Legal Name

Date of birth

Social Security Number

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Describe your child's physical attributes.

Height

Weight

Hair Color

Eye Color

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What is your child's eligibility?

Is the child registered with DDD?

Is the child eligible for Social Security Income (SSI)?

Have you applied for Social Security Income (SSI)?

Is the child adopted?

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Where does your child currently live?

Current place of residence:

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Provide information regarding your child's residential facility.

Facility name

Case manager's name

Address Line 1

Address Line 2

City

State

ZIP Code

Facility Phone Number

Facility Fax Number

Facility Email

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Has your child ever been institutionalized?

Where?

When?

Date of Release

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Provide financial information for incapacitated person.

Amount of monthly SSI recieved, if eligible for SSI:

Property

Property value

Add another property

Property

Property value

Add another property

Property

Property value

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Do you have a trust and/or will?

A supplemental Needs Trust (sometimes called a Special Needs Trust) is a specialized legal document designed to benefit an individual who has a disability. Established to Preserve Governmental Benefits And Protect Assets. Please check below.

Do you have a Special Needs Trust?

A will is one of the most important estate planning documents you can have as it protects your assets and those of your loved ones. You should review an update your Will to reflect changes in your life such as marriages, the birth of a child, death, changes of financial status or revisions of estate laws in New Jersey.

Do you have a will?

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Provide bank and deposit information for incapacitated person, if any.

Bank

Amount on deposit

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Bank

Amount on deposit

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Bank

Amount on deposit

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Please provide detailed information for the proposed guardian(s).

Full Legal Name

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone Number

Home Phone Number

Business Phone Number

Fax

Age

Social Security number

We take your privacy very seriously. This website is secure.

Relationship to child

Add Second Guardian

Full Legal Name

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone Number

Home Phone Number

Business Phone Number

Fax

Age

Social Security number

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Relationship to child

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Provide any information regarding siblings of child.

Legal Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip Code

Add second sibling

Full Legal Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip Code

Add third sibling

Legal Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip Code

Add fourth sibling

Legal Name

Date of Birth

Address Line 1

Address Line 2

City

State

Zip Code

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Provide all information for the medical doctor that will support guardianship.

Legal Name of the Medical Doctor who will support Guardianship

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Fax Number

Relationship to child:

Add a second doctor

Legal Name of the Second Medical Doctor who will support Guardianship

Address Line 1

Address Line 2

City

State

Zip Code

Business Phone Number

Fax Number

Relationship to child:

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Provide any information regarding siblings of child.

Does the person in need of guardianship have any siblings?

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Who referred you?

We'd love to know — how were you referred to us?

ex.: a friend's recommendation, our website, etc.

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End of Guardianship Questionnaire

Enter your email to complete this form.

Thank you for completing the Guardianship Questionnaire. Our office will contact you with any further questions. If you don't receive confirmation in your email, please check your junk mail.

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