Adult Guardianship Questionnaire

Adult Guardianship Questionnaire

Please complete this form to provide information for adult guardianship proceedings in Nevada. All information is confidential and required for court consideration. An Adult is someone who is at least 18 years old or 19 years old if he/she is still in high school
NRS240A DISCLAIMER - Read Carefully.

I, DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FOR GIVING LEGAL ADVICE OR LEGAL REPRESENTATION.
Case Information

Please provide details about the guardianship case.
County in Nevada where case will be filed:*
Existing case number (if any):
Proposed Ward Information

Information about the adult for whom guardianship is sought.
Full legal name of proposed ward

First NameMiddle NameLast NameSuffix
Date of birth of proposed ward.*

MonthDayYear
Date
Residential address of proposed ward.*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Length of residency in Nevada (in years).*
Primary language spoken by proposed ward.*
Describe any disabilities or incapacity of the proposed ward.*
Emergency/Temporary Guardianship Requested?*

YesNo
If yes, explain the reasons for requesting emergency or temporary guardianship.
First Custodian's Information

Please provide information for the first proposed custodian (co-guardian).
Full legal name of Custodian 1*

First NameMiddle NameLast NameSuffix
Relationship of Custodian 1 to proposed ward*
Residential address of Custodian 1*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number of Custodian 1*

Area CodePhone Number
Email address of Custodian 1*
example@example.com
Date of birth of Custodian 1*

MonthDayYear
Date
Occupation of Custodian 1*
Has Custodian 1 ever been convicted of a crime?*

YesNo
If yes, please explain Custodian 1's criminal history.
Has Custodian 1 ever filed for bankruptcy?*

YesNo
Does Custodian 1 have any potential conflicts of interest regarding this guardianship?*

YesNo
If yes, please describe Custodian 1's potential conflicts of interest.
Second Custodian's Information (If Applicable)

Please provide information for the second proposed custodian (co-guardian), if applicable. A second proposed custodian is not required.
Full legal name of Custodian 2

First NameMiddle NameLast NameSuffix
Relationship of Custodian 2 to proposed ward
Residential address of Custodian 2

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone number of Custodian 2

Area CodePhone Number
Email address of Custodian 2
example@example.com
Date of birth of Custodian 2

MonthDayYear
Date
Occupation of Custodian 2
Has Custodian 2 ever been convicted of a crime?

YesNo
If yes, please explain Custodian 2's criminal history.
Has Custodian 2 ever filed for bankruptcy?

YesNo
Does Custodian 2 have any potential conflicts of interest regarding this guardianship?

YesNo
If yes, please describe Custodian 2's potential conflicts of interest.
Other Interested Persons

List all persons who may have an interest in this guardianship (e.g., spouse, parents, adult children, siblings).
Please provide the names, relationships, and contact information (address, phone, email) for all interested persons.
Living Situation & Care Needs

Describe the proposed ward's current living situation and care requirements.
Current residence (type and address).*
Describe the proposed ward's care needs.*
List any current services received (e.g., home health, day programs).
List current medical providers (names and specialties).
Medical Information

Provide relevant medical information for the proposed ward.
List all current diagnoses of the proposed ward.*
List treating physicians (names and contact information).
List all current medications for the proposed ward.
Have any capacity evaluations been performed? If yes, provide details.
Financial Information

Provide details about the proposed ward's financial situation.
List the proposed ward's income sources (e.g., Social Security, pensions).
List the proposed ward's assets (e.g., bank accounts, investments).
List any real property owned by the proposed ward.
List any public benefits received (e.g., Medicaid, SSI) by the proposed ward.
List all debts or outstanding obligations of the proposed ward.
Does the proposed ward have a representative payee for Social Security or other benefits? If yes, provide details.
Prior Legal Documents

Identify any prior legal documents for the proposed ward.
Are there any Powers of Attorney, trusts, or advance directives regarding the proposed ward? If yes, describe and provide copies if available
Upload supporting documents (e.g., legal documents, evaluations, identification)

Upload a File

Cancelof
Preferences & Least Restrictive Alternatives

Share any known preferences of the proposed ward and least restrictive alternatives considered.
Describe any preferences expressed by the proposed ward regarding guardianship or care:
Describe any less restrictive alternatives considered (e.g., supported decision-making, POA):
NRS 240A DISCLOSURE - Read Carefully

Please read and acknowledge.
I, DEBORAH BARNHART, DOING BUSINESS AS DPS OF NORTHERN NEVADA, AM NOT AN ATTORNEY IN THE STATE OF NEVADA. I AM NOT AUTHORIZED TO GIVE LEGAL ADVICE OR LEGAL REPRESENTATION. I MAY NOT ACCEPT FEES FORGIVING LEGAL ADVICE OR LEGAL REPRESENTATION.*

I understand that Deborah Barnhart, dba DPS of Northern Nevada, is not an attorney and is acting solely as a legal document preparer.
Name*

First NameMiddle NameLast NameSuffix
Date signed by Custodian 1*

MonthDayYear
Date
Should be Empty:

Adult Guardianship Questionnaire

NRS240A DISCLAIMER - Read Carefully.

Case Information

Proposed Ward Information

First Custodian's Information

Second Custodian's Information (If Applicable)

Other Interested Persons

Living Situation & Care Needs

Medical Information

Financial Information

Prior Legal Documents

Preferences & Least Restrictive Alternatives

NRS 240A DISCLOSURE - Read Carefully