Make a Referral

If you need additional details on eligibility criteria, please review the Referral Program page. Please complete the secure online referral form below. Referrals are reviewed for appropriateness, eligibility, and capacity. If available, upload the Physician’s Report during submission. If you do not have it yet, you may download it below and submit it once completed.

Referral Form

Please note that the individual making the referral must have first-hand knowledge of the person being referred. The person making the referral may be required to provide testimony in court if the agency petitions for guardianship.

Date of Referral Submission

Month

Day

Year

Referrer Information.

Agency affiliation

Referral source

Reason for referral

Please be specific as to why a referral is being made for the referred person and if they are aware of a referral being made.

First name

Last name

Relationship to referred person

Address

Phone

Referred Person's Demographics.

First name

If middle name known, please include here.

Last name

If maiden name known, please write as (Maiden).

Residency address

Where the referred person typically lives.

Current address

If the person is not home (e.g., hospitalized).

Phone

Full social security number

Primary language spoken

Religious preference

Place of birth

City, State

Date of birth

Month

Day

Year

Relatives and Friends.

Next of kin

Please include the First/Last Name, Relationship, Address, and Phone if known for all immediate family or friends (i.e., parent, sibling, children, etc.). If spouse's information, please include their date of birth or date of death, divorce date (if applicable), and if they were in the military.

Indiana Guardianship Services, Inc. cannot file a petition for guardianship without someone being notified, so please be as thorough as possible, as this will expedite the process.

Parental information

Please include father's name and mother's name, including maiden name

Community Involvement.

Social services

Please include the First/Last Name, Relationship, Address, and Phone if known for all known provider involvement (e.g., home health, case manager, behaviorist, etc.).

Medical.

Provider information

Please include the First/Last Name, Specialty, Address, and Phone if known for all known provider involvement (e.g., primary care physician, optometrist, dentist, psychiatrist etc.).

Primary diagnosis

Related to capacity

Allergies

Long-term plan or goal

What is the most appropriate living environment for the referred person?

Level of functioning

What does their baseline look like? Does the referred individual use any durable medical equipment (e.g., oxygen, wheelchair, rollator)?

Medicare number

Include the full Medicare # and Part D provider, if applicable. If the referred person does not have Medicare, please write N/A.

Medicaid number

Include the full Medicaid/RID # and case number, if applicable. If the referred person does not have Med, please write N/A.

Legal and Estate Planning.

Is there a current legal guardian, agent under a Power of Attorney, or healthcare representative?

Unknown

Yes

If yes, include their name and contact information in the "Yes" section.

Does the referred person have a will?

Unknown

Yes

If yes, include the name of the attorney who drafted the will and their contact information in the "Yes" section.

Does the referred person have a will?

Unknown

Yes

If yes, include the name of the trustee, their phone number, and their address in the "Yes" section.

Financial.

Monthly income

Of the selected income above, please provide the monthly amounts received.

Additional assets

Please include if the individual has any of the following: financial institutions (include checking or savings), CDs, stocks, bonds, safety deposit boxes (include financial institutions), vehicles, and properties (include full addresses).

End of Life.

Does the referred person have a Full Code or Do Not Resuscitate (DNR) order?

Unknown

Full Code

Do Not Resuscitate (DNR)

Does the referred person have a preneed trust or burial plans already in place?

Unknown

Yes

If yes, include the selected funeral home, their phone number, and their address in the "Yes" section.

Does the referred person have a preference on final arrangements?

Unknown

Cremation

Notice of Physician's Report. Indiana Guardianship Services, Inc. uses the Physician's Report to determine appropriateness for services and petitioning for guardianship. As such, an application will not be reviewed without it. Pending where the individual resides, the LaPorte County Physician's Report or the Porter County Physician's Report will be used. Indiana Code 29-3-1-7.5 is included to assist a physician in determining if an individual meets the State of Indiana's criteria for an incapacitated person.

Document upload

Please upload the Physician's Report and any additional documentation the referrer feels is needed such as a face sheet, order summary, BSP, PCISP, clinical notes, etc. here. Otherwise, they may be emailed to Executive Director Kayla Shifley at kayla@inguardian.org.

Please be aware that referrals for guardianship require a person with direct knowledge of the individual (the referrer) to provide testimony explaining why guardianship is necessary. In order for you to provide testimony, would you need to be subpoenaed?

Yes

Referral acknowledgement

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By signing/typing your name, you acknowledge that the information you provided is accurate and true.