Referral Intake Form
Thank you for contacting our agency. Completing this form will be the first step needed to refer an alleged incapacitated person to the public guardianship office for services. The alleged incapacitated person must be a current resident of Osceola County, they must meet indigent status and there must be a need. This means that there are no family members, friends, or others willing to serve as their healthcare proxy, healthcare surrogate, representative payee or guardian. Guardianship through the Office of the Public Guardian is a method of last resort.

We understand that you may not have all of the information requested on this form. Please complete as much as possible. Some information is required. Submit this form and email any pertinent documents such as court documents, mental health evaluations or medical records to rabagoc@osceola-coa.com. The Office of the Public Guardian maintains a waiting list. Upon the receipt of the referral, it is likely that the AIP will be placed on the waiting list. You will be called periodically to make sure you want to maintain the person on the list and you will be contacted as they are selected to be processed for guardianship through the courts. As per Florida law, the OCCOA may not serve as guardian until duly appointed by the court.

Today's date:
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Name of Referral
Your answer
Current Address:
Your answer
Phone Number:
Your answer
Choose type of residence:
If this person resides in a facility, what was their initial admission date?
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Previous Address:
Your answer
Sex:
Date of Birth:
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Age:
Your answer
Marital Status
If married, where is spouse and why are they not taking over the care of this person?
Your answer
Primary Language
Your answer
Education Level:
Place of Birth:
Your answer
Race:
Your answer
Social Security Number:
Your answer
Are they a US Citizen?
If not, what is their resident status?
Your answer
Religion
Your answer
Emergency Contact: (list name, address, phone number)
Your answer
Relationship:
Your answer
Emergency Contact: (list name, address, phone number)
Your answer
Relationship:
Your answer
Does this person have advance directives?
If yes, please choose all that apply:
Required
Guardianship is the option of last resort. It is only for those who have no one willing and able to manage their finances or make decisions on their behalf. If this person does not have any advance directives, other options may be available. For example; a healthcare proxy can be appointed and / or social security representative payee may be appointed. If they have a DPOA or HCS, please tell us why you are applying for guardianship through the public guardianship program.
Your answer
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