Case Manager’s Referral Form to Adult Protective Services For Guardianship and Protective Placement

Before completing the Community Referral Form for Guardianship and Protective Placement, call DCDHS at 242-6200 and ask to speak to an Adult Guardianship and Protective Services social worker. The social worker will collect information about the individual’s situation and assess whether guardianship should be pursued or if a lesser restrictive option is available.

If the guardianship services social worker agrees that guardianship should be pursued, complete the attached referral form.

The attached Examining Physician’s or Psychologist’s Report, must be completed by the client’s medical doctor, psychiatrist or licensed psychologist. The doctor needs to have seen the individual and discussed with him/her the “Statement To Be Read To The Individual Prior To Examination”; this is included on the front page of the Examining Physician’s Report. The doctor must be willing to testify in Court about the individual’s incompetency.

Along with the community referral form and the Examining Physician’s Report, a short written narrative stating why a guardian of the person and/or estate needs to be completed. Include in the narrative information about what less restrictive actions have been taken to permit this person to care for him/herself without a guardian or protective placement. If protective placement is being requested, explain why this is necessary.

Please make a copy of the referral and send the original to Adult Protective Services.