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Applicant Questionnaire - Ohio
| Applicant Questionnaire Form. This is a Ohio form and can be used in General Trumbull County (Court Of Common Pleas) . |
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PROBATE COURT OF TRUMBULL COUNTY, OHIO THOMAS A SWIFT, JUDGE IN THE MATTER OF THE GUARDIANSHIP OF: CASE NO: APPLICANT QUESTIONNAIRE Name: D.O.B. Address________________________________________________________________________ Phone: ______________________Occupation/Employment: _____________________________ 1. What is your relationship to the individual? ____________________________________ 2. Are you a service provider to the individual? Yes ____ No _______ If yes, explain: ___________________________________________________________________________ 3. How long have you known the individual? _____________________________________ Describe the relationship with the individual, including how long you have known him/her, how often you meet, and activities when you meet. ___________________________ ____________________________________________________________________________ 4. Did anyone recommend that a guardianship application be filed? Yes____ No_____ If Yes, who recommended and why?______________________________________________ ____________________________________________________________________________ 5. What do you believe are the behaviors that make the appointment of a guardian necessary? ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 6. What solutions to these problems have been tried before filing for guardianship? ___________ ____________________________________________________________________________ ____________________________________________________________________________ 7. Why do you want to become guardian of the individual? ______________________________ ____________________________________________________________________________ ____________________________________________________________________________ 8. Are you in sufficiently good health and with sufficient energy to meet guardianship duties? Yes____ No____ Explain:_____________________________________________ ____________________________________________________________________________ 1 American LegalNet, Inc. www.FormsWorkflow.com 9. Do you know of anyone else who would also be interested in becoming the guardian or will be helping you fulfill guardianship responsibilities? Yes _____ No _____ Explain: ___________________________________________________________________________ ____________________________________________________________________________ 10. In general, what is your plan for overseeing the care of the individual? ______________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ a. Do you have sufficient time to fulfill guardianship duties? Yes____No ____ ______________________________________________________________________ ______________________________________________________________________ b. Are you familiar with her/his medical problems and medications? Yes _____ No _____ ______________________________________________________________________ c. List the names of any community service providers and the nature of the services they provide. (APS, VNA, Senior Services, etc.)___________________________________ ______________________________________________________________________ d. Where will the individual live? _____________________________________________ ______________________________________________________________________ e. Is this an adequate setting? _______________________________________________ f. Does this setting meet the needs of the individual? Yes ____ No _____ Explain:_______________________________________________________________ ______________________________________________________________________ g. What is the distance from your residence? ___________________________________ h. How often do you plan to visit, and how will you oversee these living arrangements? ______________________________________________________________________ i. Have social activities, recreation and entertainment been considered? Explain: ______________________________________________________________________ j. How will transportation for medical care, recreation, etc. be handled? _____________________________________________________________ k. If individual will be living with you, what arrangements can you make to take time off from these responsibilities/care? ___________________________________________ 2 American LegalNet, Inc. www.FormsWorkflow.com 11. Mental Status Observation Checklist: Record your observational impressions on a scale of 1 for significant impairment to 5 for average/normal functioning. Comment where helpful. (Circle ratings) a) Orientation (Person, Place and Time) b) Speech -------------------------------c) Motor Behavior ---------------------d) Thought Process ---------------------e) Affect ----------------------------------f) Memory--------------------------------g) Concentration & Comprehension--h) Judgment ------------------------------Comments ___________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ 11. Is the individual aware of the plans for guardianship as outlined in the above information, and is he/she in agreement? Yes____ No ____Explain:_____________________________ ___________________________________________________________________________ 13. Do you currently have a power of attorney for the individual? Yes ____No _____ If yes, describe:_______________________________________________________________ 14. Do you now or have you ever assisted the individual with his/her finances? Explain ____________________________________________________________________________ 15. Have you been charged with or convicted of a crime? Yes____ No____ 16. Is the individual a veteran? Yes _____ No _____ 17. Have you ever filed for bankruptcy? Yes_____ No_____ If Yes, explain:________________________________________________________________ ____________________________________________________________________________ Remarks: _______________________________________________________________________________ _____________________________________
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