Public Guardianship For The Elderly Program Intake Form 1

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Public Guardianship for the Elderly Program Intake Form 1Date:Personal InformationClient’s Referral Date:Client’s Full Name:Client’s Date of Birth:Client’s Social Security Number:Client Occupation:Client’s Employer:Client’s Address, Telephone:Mother’s Maiden Name:Mother’s Place of Birth:Mother’s Date of Birth:Father’s Name:Father’s Place of Birth:Father’s Date of Birth:Client’s City, County, State, andCountry of Birth:Current Residential Address:Current Mailing Address:Residential County:Type of Residence:Choose CountyDirections to Residence:Sex:Select sexFirst Language:Race/Ethnicity:Highest Educational Level Obtained:Profession:Religious Affiliation:Clergy’s Name:Veteran:Branch:Clergy’s Phone Number:Dates of Service:Select oneIntake Form 11

Support SystemMarital Status:Number of Marriages:Date of Marriage(s):Select oneSelect number of marriagesSpouse’s residential address:Type of residence:Spouse’s Name(even if deceased):Spouse’s date of death (if deceased):Spouse’s Social Security Number:If deceased, spouse’s burial location:Was spouse a veteran?If spouse deceased, funeral home:Branch:Dates of Service:Select oneVeteran’s Administration Number:Child:Address:Phone Number:Address:Phone Number:Address:Phone Number:Reason child not Conservator:Child:Reason child not Conservator:Child:Reason child not Conservator:Intake Form 12

Family Member:Address:Phone Number:Address:Phone Number:Address:Phone Number:Neighbor/Friend:Address:Phone Number:Neighbor/Friend:Address:Phone Number:Address:Phone Number:Relationship:Reason not Conservator:Family Member:Relationship:Reason not Conservator:Family Member:Relationship:Reason not Conservator:Background Information re:Family/Friends:Home Service Provider:Intake Form 13

Description of Home Services beingprovided:Other Home/Community BasedServices being received:Medical Equipment Supplier:Address:Phone Number:List of Medical Equipment:Health InformationPrimary Care Physician:Address:Phone Number:Other Physician/Specialist:Address:Phone Number:Other Physician/Specialist:Address:Phone Number:Hospital of Choice:Address:Phone Number:Pharmacy of Choice:Address:Phone Number:Medicaid Number:Medicaid Effective Date:TennCare Choices MCO:TennCare Choices CareCoordinator:Medicare Pt. A Number:Medicare Pt. A EffectiveDate:Medicare Pt. B NumberMedicare Pt. B EffectiveDateMedicare Pt. D Provider Name,Address, and Phone NumberMedicare Pt. D Number:Intake Form 14

Medicare Advantage PlanAddressPhone NumberMedicare Supplement Plan Name,Address, and Phone NumberAddressPhone NumberTennCare Choices MCOTennCare Choices Care CoordinatorCurrent Medical ConditionMedical History(Please attach the most current History &Physical examination and Physician's Orderslist if available)Current Medications Name,Amount, Dosage:Mental Status including all knowndiagnoses:Communication:Cognitive Status:Intake Form 1Ambulation:5

Financial InformationAmount of Social Security:Amount of SSI:Amount of SSDI:Non-applicableAmount of VA Benefit:Non-applicableType of VA Benefit:Draws on Self or Spouse:Select oneNon-applicableAmount of Railroad Retirement:Non-applicableOther Income:Other Income:Non-applicableAmount in Additional BankAccount:Type of Account:Bank Name:Bank Address:Non-applicableAmount in Additional BankAccount:Type of Account:Bank Name:Bank Address:Non-applicableAmount in Additional BankAccount:Type of Account:Bank Name:Bank Address:Non-applicableSafety Deposit Box:Location of SafetyDeposit Box:Select oneReal Estate Address:Address:Type of Real Estate:Name of person withKey:Is the client the soleowner?Select oneReal Estate Address:Type of Real Estate:Is the client the soleowner?Select oneIf not, who is/arethe otherowner(s)?If not, who is/arethe otherowner(s)?Personal Property (including anyvehicles, jewelry, etc.):Life Insurance Company:Amount of Life Insurance:Address and Phone Number:Is Policy paid up?Select onePolicy Number:Cash Value of Policy:Intake Form 1Beneficiary:6

Life Insurance Company:Address and Phone Number:Policy Number:Irrevocable Trust:Address and Phone Number:Policy Number:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:Monthly Expenses Amount:To Whom:End of Life WishesPOST Form?Location of POST:Advance Directive?Location of AdvanceDirective:Does the client wish to havea funeral and be buried?Funeral Home:Funeral Home Address and Phone Number:Select oneCemetery of Choice:Does the client wish to be cremated?Address and Phone Number:Crematory:Select oneFuneral/cremation paid for?Crematory Address and PhoneNumber:Actions to take with ashes/grave site:Select oneDoes the client have a will?Location of Will:Select oneAttorney who drafted Will:Individual to contact in event of death:Intake Form 17

Legal InformationDoes client have an attorney?Contact information for attorney:Select oneDoes the client have a Durable Power of Attorney?Contact information for attorney who drafted DPOA:Select oneAttorney-in-fact name:Contact information:Location of DPOA:Comments:Is the client currently underconservatorship by another person orentity?If yes, whom?Address and Phone Number:Select oneType of Service RequestedConservator of Person and PropertyDurable Power of Attorney for Healthcare and FinancesConservator of PersonDurable Power of Attorney for HealthcareConservator of PropertyDurable Power of Attorney for FinancesRequested ByName of Person Completing Application:Address and Phone Number:If there is a petitioning attorney in this case, Name:Address and Phone Number:APS Staff:APS Staff contact information:Intake Form 18

Public Guardianship for the Elderly Program Intake Form 1 . Personal Information . Client’s Referral Date: Client’s Full Name: Client’s Date of Birth: Client’s Social Security Number: . Type of Real Estate: Is the client the sole owner? If not, who is/are the other owner(s)? Real Estate Address : Type of Real Estate: Is the client the .

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