Welcome to Adult Guardianship Services

To refer someone to AGS for guardianship services, fill out and submit the AGS Intake form below, then go to http://probate.cuyahogacounty.us/home.htm Go to "Court Fiduciary Forms", go to "Guardianship", go to "Statement of Expert Evaluation." You will need to download the form, have it filled out, and personally signed by the physician. You may then mail it to Adult Guardianship Services, Intake Department, 2800 Euclid Avenue, Suite 200, Cleveland, Ohio 44115.

Client
Name:

SSN:

Intake Date:

Referred
By:

Phone:

Ext:

Organization:

Fax:

1. ADULT (Not MR/DD)

Date of Birth:

Protective Services:

Yes No

Gender:

Male Female

Veteran:

Yes No

Race:

Black White Hispanic Other

Marital Status:

Single Married Divorced Widowed

2. CUYAHOGA COUNTY RESIDENCY

Address:

City:

State:

Zip:

Home Phone:
(with area code)

Previous
Address:

City:

State:

Zip:

Length at Current Address:

Owns

Rents

Titled Owner:

Title Date:

Market Value:

All property ownership information can be obtained from Map Room at Homeowners Hotline (216) 443-7091.

3. EVIDENCE OF SUBSTANTIAL MENTAL IMPAIRMENT
(A Completed Statement of Expert Evaluation Must Accompany Intake)

Primary
Impairment
Diagnosis:

Mental
Illness:

Yes No Specify:

Previous
Guardian:

Yes No Name:

Case Manager: Phone:

Agency: Case Number:

4.INDIGENCY

Medicaid:

Yes No

Medicaid No:

Medicaid Case No.:

Medicare:

Yes No

Private Pay:

Yes No

Active Payeeship?:

Yes No Payeeship Name and Phone

Income

Amount

Source

Total

Assets

Value

Private Prop.

Real Estate

Annual Rents

Total

5. SIGNIFICANT NEXT OF KIN WHO RESIDE IN OHIO

Relative:

Address:

City:

State:

Zip:

Phone:

Relationship:

Relative:

Address:

City:

State:

Zip:

Phone:

Relationship:

6. COMPELLING DECISION (which requires legal authority to act)

	Placement		Legal		Medical		Successor Guardianship
	Financial		Maintain Placement		PASSAR/LOC Complete Date Completed		Other

If there is a deficit, how does this interfere with the person's ability to provide an informed consent to care, treatment, placement or management of financial affairs? Please be specific: