Guardianship/Physician Certification Inquiry Form

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If you are seeking out Guardianship Evaluation services from us, please fill out the below questionnaire and a member of our team will be in touch. Provide as much information as possible so that we can best assist you.

If you would like to submit a general inquiry about our services, please use our contact form: pelorusguardianship.com/contact

First Name *

Last Name *

Email *

Phone Number *

Preferred Contact *

Phone

What is the alleged incapacitated person’s (AIP) name?
*

Where does the alleged incapacitated person reside (i.e., at home, nursing home, etc.)? If AIP resides at a nursing home, provide the name of the facility.

Who is requesting this evaluation (i.e., family member, adult protective services, nursing facility, etc.)?
*

Is guardianship being actively pursued, or is a capacity evaluation needed first to determine if guardianship is needed?
*

If guardianship is being pursued, how many evaluations are needed from us? 1 or 2?
*

N/A

Please provide a brief description of what has been going on and why this is needed.
*

Which law firm is being used? It is encouraged to have an attorney in place already to help assist you with the guardianship process.
*

Which state will this guardianship application be submitted to?
*

Is there anyone likely to contest this guardianship application (i.e., another family member), or are there any other such issues or details that we need to be aware of?
*

Can this evaluation be completed via telehealth (i.e., Zoom)?
*

Yes

Not sure

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This form was created inside of NJ Memory and Behavioral Care.