Maricopa County, AZ

Step 1

Referral Form
Please be aware this form must be completed in full. If the form is incomplete it will not allow you to submit the form for referral. If necessary, please list N/A for areas that do not apply to the person you are referring. If you need to contact us with any questions the preferred method of contact is: PF@MARICOPA.GOV
Name*
Current Location*
APT/RM/SUITE #*
City*
State*
Zip Code*
Phone Number*
Location M-F 8am-5pm*
City*
State*
Zip Code*
Previous/Permanent Address*
City*
State*
Zip Code
Referral Source
Name*
Relationship*
Address*
City*
State*
Zip*
Phone Number*
Fax*
Email*
Are you making this referral on behalf of an Agency:*
1. Yes
1. No
Agency Name
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Step 2

Is this referral being made due to medical discharge issues?
1. Yes
1. No
Please give a detailed description of all facilities where referrals for placement were made, attempts to coordinate discharge with family and include any bioethics consultations.
Gender*
Date of Birth*
Date of Birth
Ethnicity*
Place of Birth*
Language*
Social Security Number
Interpeter Needed*
Religion Preference*
Education Level*
Martial Status
Is the proposed Ward a Veteran*
1. Yes
2. No
Branch of Service*
VA #
Is the Ward a resident of Maricopa County?
1. Yes
1. No
Is the proposed Ward a US Citizen and/or Legal Resident?
1. Yes
1. No
Is there a history of or any recent violent threats or actions known?*
1. Yes
1. No
Please Describe
Are there any Fire Arms or Weapons in the Home?*
1. Yes
1. No
Please Describe
Please describe the current living conditions and/or concerns i.e. hoarding/infestation/biohazards*
Are there any concerns for Safety this office should be aware of when conducting a visit?*
1. Yes
1. No
Please Describe
Is the person at risk of loss of money or property?*
1. Yes
1. No
Please Describe
Is the person at risk of abuse or currently being harmed?*
1. Yes
1. No
Please Describe
Criminal History*
1. Yes
1. No
Pending Criminal/Legal Matters*
1. Yes
1. No
Please Describe
Substance and Drug History:*
1. Yes
1. No
Please Describe
Are there any known directives
Do Not Resuscitate (DNR)
1. Yes
1. No
1. Unknown
Power of Attorney (POA) - Medical
1. Yes
1. No
1. Unknown
Power of Attorney (POA) - Financial
1. Yes
1. No
1. Unknown
Any Known Instructions
1. Yes
1. No
1. Unknown
Wills
1. Yes
1. No
1. Unknown
Alternatives to Guardianship: Guardianship is a serious step and should only be sought as a last resort. Please check below the alternatives to guardianship that have already been tried.
1. Assistance from family and/or friends
2. Case Management Services
3. Clinical and Mental Health Support Services
4. Day Treatment Activities
5. Home and Community Based Support Services
1. Homemaker Services
2. Meals on Wheels
3. Representative Payee Services for SSA or VA
4. Senior Center Activities
CURRENT DIAGNOSIS
Medical Diagnoses*
Psychiatric Diagnoses*
Psychiatric
Court Order for Treatment
1. Yes
1. No
MH Cause Number*
Expiration Date*
Expiration Date
Check all that Apply:*
1. Gravely Disabled
1. Persistently Acutely Disabled
1. Danger to Self
1. Danger to Others
Purpose of Guardianship: How will a guardian benefit the proposed ward? Describe what unmet need exists that cannot be addressed by another agency, service or alternate to guardianship
Situation: Briefly describe the chronology of recent events leading up to this referral
PLEASE CHECK ALL THAT APPLY TO THE PROPOSED WARD ABILITY TO MANAGE:*
1. Alert
2. Responsive
3. Confused
4. Non-Verbal
5. Oriented x #_____
6. Delusional
7. Cooperative
8. Wanders
9. Non-Responsive
1. Inappropriate Social Norms
2. Disheveled Appearance
3. Non-ambulatory
4. Incontinent of Bowel
5. Incontinent of Bladder
6. Feeds Self
7. Prepares Food Independently
8. Prepares Food w/assist
9. Independent All
1. Moderate Assistance
2. Requires Prompting
3. Supervision
4. Self-Dress
5. Self-Bathing/Grooming
6. Self-Toileting
7. Total Care
8. Independent Chores
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Step 3

Please explain why the proposed Ward is unable to care for their Activities of Daily Living (bathing, dressing, grooming, toileting, walking, eating):
Income Type and Amount
SSA Amount
Retirement / Pension Amount
SSI Amount
Annuity Amount
VA Amount
Railroad Amount
Civil Services Amount
Other Amount
Is there a Payee in place
1. Yes
1. No
Payee Name
Are there any bank accounts, trusts, annuities, life insurance, or retirement accounts:*
1. Yes
1. No
PLEASE LIST, NAME, ACCOUNT TYPE, ACCOUNT NUMBER, LOCATION
Is there any land, house(s), or building(s) this person owns?*
1. Yes
1. No
PLEASE LIST, ITEM, ADDRESS, CITY, STATE, ZIP
MORTGAGE INFORMATION
HOMEOWNERS INSURANCE CO NAME
Are there any vehicles?*
1. Yes
1. No
PLEASE LIST, MAKE, MODEL, YEAR, LOCATION
Is there additional information to add regarding the real and personal property?
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