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Indiana
Guardianship Services, Inc.

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- Mission, Vision, and Values
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What We Do
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Referrals & Intake
Referral Program
- Make a Referral
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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.

First name*

Last name*

Relationship to referred person*

Address*

Phone*

Email*

Agency affiliation*

Referral source*

Skilled Nursing Facility

Home Health

Supported Living/Group Home

Hospital

Adult Protective Services

Other

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.

Referred Person's Demographics.

First name*

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*

Social security number*

000-00-0000

Primary language spoken*

Religious preference*

Place of birth*

City, State

Date of birth*

Month

Day

Year

Race*

Asian

American Indian/Alaska

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White/Non-Hispanic

Other

Gender*

Female

Male

Other

Marital Status*

Single

Married

Widowed

Divorced

Relatives and Friends.

Relation #1*

Please include the First/Last Name, Relationship, Address, and or Phone

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.

101 W 2nd Street, STE 200, Michigan City, IN 46360, United States

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