Guardianship / Conservatorship Client Worksheet

Thank you for choosing Alderwood Legal, PC for your protective proceeding matter. Please complete this worksheet as completely and accurately as possible. You will have an opportunity to edit your responses as the case progresses. If you have any questions about how to complete this form, please contact our office for assistance.
ALDERWOOD LEGAL, PC
565 SE 9^TH STREET
BEND, OREGON 97702
503.683.3224
541.550.1333
WWW.ALDERWOODLEGAL.COM

Information about the person who needs a guardian and/or a conservator:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:
Format: (000) 000-0000.
SSN:
Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age:
Current Location:
County:
Your relationship to the person:
If in a hospital or care facility, when admitted:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Information about the person's spouse:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age:
Telephone:
Format: (000) 000-0000.
If the person lives with a domestic partner, friend, or relative, information about him or her:
Name:

First NameLast Name
Relationship:
Age:
Information about the children or other closest living relatives of the person (For example, parents, brothers and sisters, aunts and uncles, or nieces and nephews):
Relationship:
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Age:
Telephone:
Format: (000) 000-0000.

Information about the person's lawyer(s). If there is more than one lawyer, please send this information via email.
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:
Format: (000) 000-0000.
Briefly describe the person's physical and mental condition:
Diagnosis(es):
Language/communication (expressive/receptive):
Are there any safety concerns? If yes, please explain.
School:
Class/Program:
Successes:
Challenges:
Self-care Needs:
Decision-making:
Does the person need help making medical and health care decisions?
If yes, please give examples showing why the person needs this type of help:

Does the person need help to take care of basic physical needs like food, shelter, clothing and personal cleanliness?
If yes, please give examples showing why the person needs this type of help:
Does the person need to stay in a care facility, or will they need to be moved to a care facility?
If yes, please give examples showing why the person needs to be in a care facility:
Does the person need help to respond to other problems?
If yes, please describe the other problems:
What other kinds of help and services have been tried in the past year? For example, help with housekeeping or bathing; someone setting up the medication or balancing the checkbook; medical or mental health treatment.
Does the person need help making decisions about finances and property?
If yes, please give examples showing why the person needs this type of help:
Who else has personal experience with the situations you described?
For example, caregivers, case managers, other family members, friends and neighbors. If there is an county case manager, please provide contact information.
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Format: (000) 000-0000.

Does the person receive Medicaid assistance (Oregon Health Plan), food stamps, or other public assistance from the Oregon Department of Human Services?
Please answer the following questions if the person needs a conservator.
NOTE: A conservator is usually needed if the person, who cannot manage his or her finances, has assets worth more than $10,000 or if money or property must be recovered.
If the finances are already being managed by someone else, like a trustee, please describe the arrangement:

Real Property:

Bank Accounts:

Rows	Bank or Institution	Account Number	Balance
1
2

Brokerage Accounts:

Retirement Plans/IRAs:

Rows	Plan Administrator or Institution	Account Number	Balance
1
2

Annuities / Life Insurance:

Vehicles:

Other Assets:

Rows	Description	Value
1
2