Virginia Public Guardian Program
REFERRAL INSTRUCTIONS
Before completing the attached referral form, review the information on the Public Guardian Program
web page
to ensure you understand how the program works, the criteria, and the referral process.
DO NOT start the court process unless the individual has been offered an open slot. At that point, the local program director will provide instructions, and you will need to move forward immediately to prevent the slot from being offered to someone else.
Does the individual receive services from a Community Services Board (CSB) or Behavioral Health Authority (BHA)?
If NO, follow the General Instructions.
If YES, the support coordinator/case manager should follow the Special Instructions.
GENERAL INSTRUCTIONS
To determine where to submit the completed referral, refer to the list of Local Public Guardian Programs and their catchment areas appended to the referral form. The referral may be submitted to any program serving the locality where the referred person lives (or will be living). Submission by email is preferred, encrypted if possible. If you mail the referral, please be sure to keep a copy.
If you have questions, feel free to contact the local program director before submitting the referral.
Each Local Public Guardian Program has limited slots, so the individual may be placed on a waitlist. The program director will acknowledge receipt of the referral and may contact you with follow-up questions. If you do not respond timely, the referral cannot move forward.
SPECIAL INSTRUCTIONSfor CSB Support Coordinators and BHA Case Managers Only
The Public Guardian Program has client slots reserved for individuals who
meet the eligibility criteria described above,
are receiving services from a CSB or BHA, and
were diagnosed with an intellectual disability prior to age 18 or a developmental disability prior to age 22.
The Department of Behavioral Health and Developmental Services (DBHDS) maintains the waitlist for these slots. Do not submit the referral directly to a Local Public Guardian Program. Follow
DBHDS' instructions
for submitting the referral and requesting reimbursement.
Exceptions
1. If your client currently has a private guardian, do not submit the referral to DBHDS. Follow the General Instructions.
2. If your client also has a mental health diagnosis that substantially contributes to their mental incapacity, you have the option to follow the General Instructions or submit the referral to DBHDS.
Version: Feb 2026
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VIRGINIA PUBLIC GUARDIAN PROGRAM REFERRAL
This form is periodically updated. The most recent version is available on DARS' Public Guardian Program web page. If the cover page is missing, please obtain and review the instructions before proceeding.
REFERRING PARTY
Your name
Your title or relationship to the referred person
If you are making this referral in your professional capacity, provide the name of your employer
Your mailing address, phone number, and email address
For CSB/BHA employees only
(1) Name of the attorney who will prepare the petition:
(2) Name, title, and email of your supervisor:
INFORMATION ABOUT THE REFERRED INDIVIDUAL
Name (including middle name and preferred name, if different)
Date of Birth
-
Month
-
Day
Year
Date
Place of Birth
Race
Ethnicity
Sex at birth
Gender identity (if different)
Marital Status
Citizenship/immigration status
Preferred language
Other language(s)
Mark each of the following that apply:
The individual is mentally incapacitated (i.e., incapable of receiving and evaluating information and making decisions, to the extent that they lack the capacity to meet their health, safety, and therapeutic needs).
There is no other suitable person willing and able to serve as guardian.
The individual is indigent (without income or assets adequate to pay for guardianship services).
Given that appointment of a guardian will resultin the loss of most rights and public guardianship slots are in high demand, explain why less restrictive alternatives (for example, supported decision making and additional services) are not adequate or have been ruled out.*
* Note that making poor decisions is not a sufficient reason for the court to appoint a guardian. A guide titled "Less Restrictive Options in Virginia" and general information on guardianship are available at www.guardian.vacourts.gov.
Family Members and Friends
Version: Feb 2026
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VIRGINIA PUBLIC GUARDIAN PROGRAM REFERRAL
For each of the individual's known family members and other significant people in their life, provide the name, relationship, and contact information. Please describe the extent of their involvement in the person's life, and why they have been ruled out as a potential guardian.
Click here
Current Appointments
Does the individual currently have a guardian?
No
Yes
If Yes, provide their name, relationship to the protected person (e.g., family member, professional), contact information, and court of appointment, and explain why they will not continue to serve.
Click here
Does the individual currently have a conservator?
No
Yes
If Yes, provide their name, relationship to the protected person, contact information, and court of appointment.
Click here
Diagnoses
I. Diagnoses affecting the individual's mental capacity
Intellectual disability diagnosed prior to age 18?
No
Yes (specify type and severity below)
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Developmental disability diagnosed prior to age 22?
No
Yes (specify type and severity below)
Click here
Other (e.g., severe mental illness, dementia, brain injury, etc.)
Click here
II. Other significant diagnoses (e.g., kidney failure requiring dialysis or hearing loss requiring accommodation)
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Other Mental Health & Medical Information
Substance abuse history and current usage
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Psychiatric hospitalizations in the past five years (including location and dates, if known)
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Current medical and mental health providers (name, type/specialty, practice group name, city)
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Health Insurance Coverage Mark all that apply:
Medicare - Member #: Click here
Medicaid - Member #: Click here
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VIRGINIA PUBLIC GUARDIAN PROGRAM REFERRAL
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Behavioral/Criminal History
Describe any history of violent, destructive, or threatening behavior
Describe any other significant behavioral issues, including a history of running away
List criminal arrests and convictions (include jurisdictions and dates, if known). If there are any pending legal proceedings, provide the type, jurisdiction, and upcoming court dates.
Residence
What is the individual's current residence type or living situation (for example: group home, nursing home, lives independently, etc.)? Provide the facility name, if applicable.
Current address and phone number (include the zip code and county)
Length of time at this address
Provide the permanent address if different, and explain:
Length of time at this address
If there is a plan for this person to move to a different area, provide details:
Income
Total monthly income from all sources:
Mark one:
Gross
Net
Income
Rows
Amount
Source
Amount
Social Security Disability (SSDI)
Social Security Retirement (SSA)
Supplemental Security Income (SSI)
Benefits
Medicaid Waiver:
I/DD Waiver
CCC Plus Waiver
Housing Assistance:
Auxiliary Grant
Section 8
Comments:
Version: Feb 2026
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VIRGINIA PUBLIC GUARDIAN PROGRAM REFERRAL
Bank Accounts and Assets
To assist in the determination offinancial eligibility, provide information about the referred person'sbank account balance, cash resources, and any other known assets—such as trusts (including a Special Needs Trust), ABLE account, investment accounts, IRA, life insurance, vehicles, real estate, etc. Provide the address of any real estate, if known.
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Advance Planning and Supports
If the individual has any of the following, mark the box and provide the name and contact information of the agent or responsible party in the column to the right. Attach a copy of the document if available.
Power of Attorney
Should be Empty: