County of San Diego Public Guardian
Request for Conservatorship Investigation
Referring Party Information
Fields with a red label are required:
Please complete as much information as you know:
If you do not hear from a Public Guardian Investigator in 3 business days, please contact 1-800-339-4661 and ask to be transferred to the assigned Deputy Public Guardian.
Submit
Last Name:
First:
Relationship:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Are you making this referral on behalf of an agency?
Yes
No
Agency Name:
Relationship:
Attorney/PF
APS
Bank/Credit Union
Court
Doctor
Family/Friend
Hospital
Law Enforcement
LPS
Medi Cal
Neighbor
Self Referral
SNF
Other
Is agency's contact information different from yours?
Yes
No
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Is there a person other than yourself who should be contacted regarding this referral?
Yes
No
Last Name:
First:
Relationship:
Phone:
Fax:
Email:
Address:
Apt #/Room #:
City:
State:
Zip:
Submit
Fields with a red label are required:
Please complete as much information as you know:
Proposed Conservatee Information
Last Name:
First Name:
Middle Name:
Suffix:
Sr.
Jr.
I
II
III
IV
AKA's:
Date of Birth:
Place of Birth:
Gender:
Female
Male
Ethnicity:
American Indian
Asian
Black/African American
Hispanic
Not Reported/Unknown
Other Race
White/Caucasian
Social Security Number:
Marital Status:
Single
Married
Divorced
Widowed
Partnered
Spouse Last Name:
First Name:
Maiden Last Name:
Does Proposed Conservatee have a Trust?
Yes
No
Unknown
Does Proposed Conservatee have a Will?
Yes
No
Unknown
Does Proposed Conservatee have a POA/DPOA?
Yes
No
Unknown
POA Last Name:
First Name:
Phone:
Address
Home Facility:
Address:
Apt #/Room #:
City:
State:
Zip:
Phone:
Is the individual currently residing at a location other than their home address?
Admitted Date:
Current Facility:
Address:
Apt #/Room #:
City:
State:
Zip:
Phone:
Medical Information
Care Provider Last Name:
First Name:
Phone:
Doctor Last Name:
First Name:
Phone:
Medical Insurance:
Diagnoses:
Medications:
Activities of Daily Living (Please mark only those areas where assistance is needed)
Walking
Cooking
Personal Care
Shopping
Housekeeping
Transferring
Laundry
Eating
Paying Bills
Other Needs:
Is proposed conservatee capable of accepting assistance?
Yes
No
Unknown
What services have been provided in the past year (check all that apply)
Home Maker Services
Rep Payee Referral
LPS Conservatorship
Estate Management Services
Other Information (check all that apply)
Uses Walker/Cane
Incontinent
Smokes
Wanders
Has animal(s)
Uses hearing aids
Homeless
Under LPS Conservatorship
Is there any additional information we need to know regarding Proposed Conservatee:
Relationships
Add Relationship
Did the proposed conservatee or his/her spouse serve in the military?
Service Person's Information
Last Name:
First Name:
Serial #:
Branch:
Rank:
Service Began:
Service Ended:
Monthly Income (Use Numbers only. If unknown leave as blank.)
SSA:
Pension:
SSI:
Military Pension:
VA:
Civil Service:
Rental:
Annuity Payments:
Other:
Amount:
Monthly Expenses (Use Numbers only. If unknown leave as blank.)
Mortgage:
Insurance:
Care Bills:
Other:
Amount:
Assets: Check all that apply
House
Automobile(s)
Mobile Home
Jewelry
Furniture
Bonds
Oil Leases
Rental(s)
Life Insurance Policy
Notes Receivable
Who:
Stock(s)/Securities
Company/Broker:
Other Asset
List:
Bank Accounts
Add Bank Account
Please give the concerns as to why a conservatorship by the Public Guardian is needed
Primary Reason for Referral:
5150
Emotional Abuse
Financial Abuse
Financial Self-Neglect
Neglect By Others
Physical Abuse
Self-Neglect
Please Elaborate:
Estate Referrals: State below the specific indications of the proposed conservatee's substantial inablity to manage his/her own financial resources or resist fraud or undue influence. Also, Please describe any variations from prior spending patterns.
Person Referrals: State below the specific facts supporting your allegation that the proposed conservatee is unable to provide properly for his/her own needs for physical health, food, clothing and shelter. Please provide specific examples from the proposed conservatee's daily life showing significant health patterns.
Ability To Give Informed Medical Consent: If you are requesting a determination that there is no form of medical treatment for which the proposed conservatee has the capacity to give an informed consent, state below why you allege that the proposed conservatee is unable to understand the nature and seriousness of any illness, disorder, or defect that he/she has or may develop.
Capacity: Describe any deficits the proposed conservatee may have in their level of conciousness or their ability to attend and concentrate
Describe any deficits the proposed conservatee may have in their short and long term memory
State below the proposed conservatee's ability to live in or return to their residence home.