Guardianship Questionnaire

Guardianship Questionnaire

PROPOSED GUARDIAN #1

Full name    Other Names/Maiden name    Date of Birth/Birth Place

State ID/Drivers License No.    Social Security No.

Housing: Rent Own Buying    Amount Per Month

How Many Bedrooms/Baths    Is It A House? Or Apt.?

Do You Plan To Remain In This Residence, Or Are You Looking For Another Location? Yes No

List Addresses for Past Five Years:

1.    Phone No.    From    to    Own Rent Rent/Mortgage $ /Month

2.    Phone No.    From    to    Own Rent Rent/Mortgage $ /Month

3.    Phone No.    From    to    Own Rent Rent/Mortgage $ /Month

High School Graduate?    If Not, Grade Last Attended    Place & Name Of High School    Age Left School    Reason

List College Or University Attended: Degree Or Units/Majors

List Any Previous Marriages, Including Name Of Spouse, Date, How Terminated, And Date Of Final Separation:

Your Health Good Fair Poor

State Any Medical Conditions Currently Being Treated For

Medications – Name, Amount, Reason, How Often Taken:

Attending Counseling? Yes No Type    Name of Counselor

Have You Ever Been Convicted Of An Offense Other Than A Minor Traffic Violation? Yes No If Yes, Please List Date: City: Outcome

Have You Ever Been On Or Are You On Probation/Parole? Yes No If yes, Officer/Agent’s Name: County/Phone No.

Do You Drink Alcoholic Beverages? Yes No If yes, how much/often?

What Drugs Do/Did You Use?    When Did You Last Use?

How Much/Often? Daily Weekly Monthly Cost?

Have You Ever Entered Or Completed An Alcohol Or Drug Treatment Program? Yes No If Yes, Give Details

Have You Ever Had Contact With A Child Protective Service Agency? Yes No If Yes, Give Details And County

Have You Ever Been Arrested For Domestic Violence? Yes No If Yes, Give Details

Name And Address of Employer

Phone    Title    How Long?    Days You Work    Hours    Gross Salary

Other Income:

AFDC SOC. SEC. UNEMPLOYMENT CHILD SUPPORT

Amount $ Mo For Whom Received

Total Gross Monthly Income    Total Gross Monthly Expenses

Have You Ever Filed Bankruptcy Yes No If Yes, Date Place Result

Have You, Your Spouse Or Either Parent Ever Been Involved In Any Of The Following?:

Received Counseling For Domestic Violence? Yes No

Domestic Dispute Where Law Enforcement Was Called Yes No

Been The Subject Of A Domestic Or Civil Restraining Order? Yes No

If Yes For Any, Give Date/Place/Case No./Court/Law Enforcement Agency/And Details For Each Incident:

PROPOSED GUARDIAN #2

Full name    Other Names/Maiden name    Date of Birth/Birth Place

State ID/Drivers License No.    Social Security No.

Housing: Rent Own Buying    Amount Per Month

How Many Bedrooms/Baths    Is It A House? Or Apt.?

Do You Plan To Remain In This Residence, Or Are You Looking For Another Location? Yes No

List Addresses for Past Five Years:

1. Phone No. From to Own Rent Rent/Mortgage $ /Month

2. Phone No. From to Own Rent Rent/Mortgage $ /Month

3. Phone No. From to Own Rent Rent/Mortgage $ /Month

High School Graduate?    If Not, Grade Last Attended    Place & Name Of High School    Age Left School    Reason

List College Or University Attended: Degree Or Units/Majors

List Any Previous Marriages, Including Name Of Spouse, Date, How Terminated, And Date Of Final Separation:

Your Health Good Fair Poor

State Any Medical Conditions Currently Being Treated For

Medications – Name, Amount, Reason, How Often Taken:

Attending Counseling? Yes No Type Name of Counselor

OTHER ADULTS RESIDING IN THE HOME OF PROPOSED GUARDIAN(S)

Full Name Other Names/Maiden Name

Relationship Date of Birth Occupation

Does This Person Have Any Criminal Record? Yes No If Yes, Where/When? Charges

OTHER CHILDREN RESIDING IN THE HOME OF PROPOSED GUARDIAN(S)

Full Name Date Of Birth Name And Address of School

Relationship

BIRTH PARENTS

Natural Mother: Full Name Other Names/Maiden Name

Date of Birth Drivers License/State ID No. Social Security No.

Last Known Address/Dates Lived There

Name And Address Of Employer Telephone No.

Is Mother In Agreement With Guardianship? Yes No

Does Mother Contribute To Support Of Child? Yes No If Yes, How?

Does Mother Visit With The Child? Yes No If Yes, How Often?

Does The Mother Visit The Child Outside Of Your Home? Yes No

Does The Mother Send Cards, Gifts Or Call For Holidays? Yes No

Does The Mother Express An Interest In School Issues? Yes No

Does Mother Express An Interest In Health Issues? Yes No

Does The Mother Have Any Other Children? Yes No

If Yes Name: Date Of Birth

If Yes Name: Date Of Birth

If Yes Name: Date Of Birth

Has The Mother Ever Been Arrested And/Or Convicted? Yes No If Yes, Give Date/Place/Charges

Has The Mother Ever Been Investigated By Child Protective Services? Yes No If Yes, Give Date/Place/Charges

Is There A Custody Order (From Divorce, Separation, Paternity) For This Child In Any County? Yes No If Yes, Give County/Case No. And Any Details

Natural Father

Full Name Other Names

Date of Birth Drivers License/State ID No. Social Security No.

Last Known Address/Dates Lived There

Name And Address Of Employer Telephone No.

Is Father In Agreement With Guardianship? Yes No

CHILDREN

Child(ren) Under Guardianship

First Child: Name Date/Place Of Birth Social Security No.

Relationship Date Placed With Guardian

Previous Schools:

Name Address

Name Address

Name Address

Name/Address Of Child’s Physician

Results of Drug Test At Birth

Do You Suspect Mother Used Drugs When Pregnant? Yes No

Does The Child Have Any Behavioral Problems And/Or Needs Yes No

If Yes, Explain Yes No

Difficulties In School? Yes No

Special Needs? Yes No

Criminal Involvement? Yes No

Does The Child Have Any Assets To Be Protected Yes No If Yes, Describe Asset

Is The Child A Beneficiary Under Any Insurance/Investment/Annuity/Trust, Etc.? Yes No If Yes, Provide Name of Instrument in Which Named As Beneficiary, Owner’s Name, And Account Number:

Second Child

Name Date/Place Of Birth Social Security No.

Relationship Date Placed With Guardian

Previous Schools:

Name Address

Name Address

Name Address

Name/Address Of Child’s Physician

Results of Drug Test At Birth

Name Of Social Worker

Business Phone No. Fax No. E-Mail Address

Has Anyone Pursued Guardianship Or Conservatorship Of The Proposed Ward(s) Before? Yes No

Does The Proposed Ward(s) Have Any Children? Yes No

Please List The Next Of Kin Of The Proposed Ward(s), Including Their Addresses And Their Relationship To The Proposed Ward:

Are Any Of The Next Of Kin Currently In The United States Armed Service? Yes No

If The Child(ren) Live(s) With You, When Did You Get Custody And How?

Do The Child(ren)’s Parents Agree With The Guardianship? Yes No

Is There Anyone Who Opposes Your Guardianship? Yes No If Yes, Explain

How Do You Plan To Care For The Needs Of The Child(ren) With Regard To Housing, Finances, Schooling, Child Care And Supervision, Discipline And Guidance?

Do(es) The Child(ren) Have Any Special Problems? Yes No If Yes, How Are You Qualified To Help With These Problems?

Do You Expect The Proposed Ward(s) To Contest The Guardianship? Yes No

Is This An Emergency Requiring Pursuit Of A Temporary Guardianship? Yes No

Does The Proposed Ward(s)’s Psychiatrist Or Physician Support The Guardianship? Yes No

What Types Of Health Insurance, If Any, Does The Proposed Ward(s) Have Available? Yes No

Please Describe Your Contacts With The Child(ren), Including Whether The Child(ren) Has Ever Lived In Your Home Previously, The Extent Or Your Contacts With Him/Her/Them, And The Extent Of The Child(ren)'s Contacts With Other Members Of Your Household, If Any

Please State, In Detail, The Reasons That The Child(ren)'s Mother And/Or Father Are Unfit To Serve As The Child's Legal Guardian: Yes No

Please State, In Detail, Why You Believe That Your Obtaining Guardianship Is In The Best Interest Of The Child(ren), Including The Reasons Why Guardianship Is Appropriate And Why You Are The Best Person To Be The Guardian

Please Describe The Contact Your Child(ren) Would Have With His/Her/Their Parents If Guardianship Is Granted To You, Including How Such Contacts Will Be Scheduled, Their Frequency And Duration

PLANS FOR CHILD CARE IF NEEDED

If Child Care Provider Is Licensed: Name Address Phone

If Child Care Provider Is Unlicensed:

Name Address Date Of Birth Social Security No.

Phone Relationship To Child