Yellowstone Guardianship Application for Consideration
This application must be completed in full. The Council will not consider guardianship without a physician letter of incapacity and good faith effort to find family or interested parties to fill the role of guardian.
Please review our scope of service document at https://www.bigskyseniorservices.org/yellowstoneguardianship.html prior to completing this application.
Complete this checklist and send in with your application:
*
Fully Completed Application
Physician’s letter or statement of incapacity and need of guardianship (Please see below for necessary elements to be included in a letter or statement)
Court Visitor Recommendation (Please see below for necessary aspects of the court visitor role)
Good faith effort to find family or interested parties to be the guardian
Facility face sheet, most recent H&P or hospital summary, medication list
Referral made by
*
Email of referrer
*
example@example.com
Date of referral
*
-
Month
-
Day
Year
Date
Phone Number of referrer
*
Please enter a valid phone number.
Full name of person needing guardianship
*
First Name
Last Name
Maiden name
Date of birth
-
Month
-
Day
Year
Date
Birthplace
Residence (name of facility)
Primary Physician
Reason for referral
*
Previous guardian or Power of Attorney
Phone (previous guardian or POA)
Please enter a valid phone number.
Email (previous guardian or POA)
example@example.com
Synopsis of person's functioning and medical conditions
List top 5 diagnoses
Does this person have a POLST?
*
Yes
No
Date of POLST
-
Month
-
Day
Year
Date
Does this person have a burial contract?
*
Yes
No
Where
Financial status- Does this person have? (check all that apply)
*
Personal Property, e.g., house, car
Social Security
Medicare
Supplemental Security Income
Medicaid
Does this person have a Representative Payee?
Yes
No
Contact information for Representative Payee
Does this person have a Court Appointed Conservator?
Yes
No
Contact information for Court Appointed Conservator
Does this person have personal assets greater than $2000?
*
Yes
No
If yes, in what accounts?
Checking Account
Savings Account
Pension
IRA
Insurance (medical, life)
Other, explain
List all known family, or interested parties with contact information, if known:
1. Name
First Name
Last Name
Address
Contact Information
Relationship
2. Name
First Name
Last Name
Address
Contact Information
Relationship
Any additional information you wish to share?
Physician's letter or statement should include:
· A description of the nature and degree of the present incapacity · Need for guardianship · Date of the last evaluation/examination -OR- * Complete and sign our Physician Statement of Incapacity and Need for Guardianship found at https://www.bigskyseniorservices.org/yellowstoneguardianship.html
Upload Physician's statement
*
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Court Visitor (please consider this role or ask someone else familiar with this case)
This individual may be a case worker, social worker or other professional willing to serve as a Court Visitor in this matter. The court will appoint as “visitor” a person who has experience or expertise in treating, evaluating, or caring for persons with the kind of disabling condition that is alleged to be the cause of the incapacity. The visitor interviews the person, visits their present place of abode, and submits a written letter to the court recommending whether the guardianship should be granted.
Name
First Name
Last Name
Address
Contact Information
Profession
You are welcome to present your referral at our monthly meeting, held the first Thursday of the month except for July, at 4:00pm. Contact Becky Wiehe at 406-259-3111.
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