Emergency Referral Form

Emergency Guardianship Referral Form

for non-emergencies, please use our other referral form
To refer someone for Emergency guardianship services, please complete this form, and make sure the following items are included:
- This referral form, the attached Next of Kin, and the Financial Information
- A Statement of Expert Evaluation (completed within the last 90 days)
- The Supplement for Emergency Guardianship signed by a licensed physician (completed within 7 days of submitting this form to ONI)
- All other documents where applicable/indicated on this form
please be advised that you will not be able to submit this form without uploading the required documents.
Check this box to confirm that you are submitting an emergency referral

ONI accepts referrals from it's Guardianship Services Partners only. Let us know who is making the referral
Name of person making this referral:

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Please select the TYPE of guardianship this application is for
*Guernsey Co. Partners/Referrals will be required to upload a birth certificate
Please select the organization making the referral (leaving this blank will result in delays in the referral process)
Why does this person need a guardian? (background information)
Please explain the nature of the emergency including what needs to happen in the first 72hrs of guardianship to address the emergency:
Is this a transfer from an existing guardian?
If YES please check all that apply
If the previous guardian is resigning they will need to submit a resignation letter to the court that must be submitted with this referral

Tell us about the person you are referring:
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SSN
How long have they lived at this address?
Are they currently somewhere other than this address?
If YES where?
Address
Does this person know about this referral
Do they make some of their own decisions even if they need support to do so?
In what ways does this person communicate?

Who else could give us important information about this person if we need it?

Rows	Name	Relationship	Contact Info
1
2
3
4

What kind(s) of decision(s) does this person need a guardian to help with?

Rows	Explain
Everyday Life
Health
Home Stuff
Legal Matters
Money
Relationships
Safety/Behavioral
Work/Career
Other

Financial Information:
The court may waive the guardianship application fee(s) if they find the person to be indigent. Please provide financial information about the person so we may file for indigency on their behalf if applicable. For guardian of estate, this is critical information for us to gain access to accounts.

Please do not leave a field blank.

If you have no financial information please enter “0” or “N/A” on the “income” box.

Income/Expenses

Rows	Current Monthly Income	Source(s) of income	Total Monthly Expenses
Amount

Does this person qualify for Medicaid?
Is the person a beneficiary of a trust/special needs trust?

What Financial Accounts does this person have?

Rows	Name of bank or institution
Checking
Savings
Pension
Other

Value of other asset(s) -- please mark "0" if info is unknown

Rows	Value of other Assets
Real Estate
Bank Accounts
Automobile
Other (stocks, bonds, IRA, etc.)

Next of Kin
Please complete the Next of Kin section on this page to the best of your ability. The moreinformation we have the quicker we can move forward with the application for guardianship. As it is required by most Probate Courts: Please list all known next of kin (extended family, parents,siblings) even if they are not involved in the person’s life or are deceased

If no one is known, please mark "N/A".
Name

First NameLast Name
Relationship to person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Relationship to person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Relationship to person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Relationship to person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Relationship to person
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of birth

MonthDayYear
Date

What's Next?
1. Review referral and make sure you have completed and uploaded all required documents. And that all evaluations are signed and dated appropriately:
- Expert Evaluation: Completed within 90 days by a licensed physician or licensed clinical psychologist.
- Supplement Form for Emergency Guardianship: Completed by a licensed phasician within 7 days of submitting a referral to ONI
Submit referral form. If you have any questions about this process you can email referrals@ohionetworkforinnovation.com

2. ONI begins processing referral (immediately)

3. An ONI Guardian Representative reaches out to referral source to:
1. Gather additional information
2. Discuss less-restrictive alternatives
3. Schedule a meeting with the person being referred
4. ONI files guardianship application with the court (within one week of receiving complete referral)

5. ONI attends guardianship hearing (determined by court, after receipt of complete application and any application fees)
Expert Evaluation (completed with in 90 days for new referrals. Referrals for Guardianship transfers do not require a new evaluation, but we request you submit a copy of the most recent evaluation with your referral).

Cancelof
Supplement for Emergency Guardianship

Cancelof
Birth Certificate (Guernsey Co. Only)

Cancelof
Previous Guardian Resignation Letter

Cancelof
I confirm that the Court has granted permission to submit this referral without the following documents
Should be Empty:

Emergency Guardianship Referral Form

Tell us about the person you are referring:

Financial Information:

Next of Kin

What's Next?