Inyo — Referral for Probate Conservatorship, 223.17 KB

Source: https://www.inyocounty.us/sites/default/files/2025-05/NewPAPGReferralform.pdf

County of Inyo Office of Public Guardian/Patricia Barton 1360 N Main Street, Suite 220 Bishop, California 93514 Phone: (760) 873-5894 Fax: (760) 873-8835

REQUEST FOR PROBATE CONSERVATORSHIP INVESTIGATION

Referring Agency or Individual:

Name

Address

Phone Email

Client Information:

Name DOB

Current Address

Home Address

Phone Number SSN

Medicare/Med DL Number and i-cal/Insurance State

Marital Status Religion

Usual Veteran

Occupation

Doctor Last Appt Date

Spouse, Relatives, Friends, Neighbors, any contacts made:

Name Relation Address Phone # Have you made contact?

Income:

Source (Social Security, Retirement, etc.) Monthly Amount

Assets: (Please include approximate value and location of asset)

Real Property Household Items Vehicles Mobile Home

Bank Accounts Life Insurance Stocks/Bonds Other

Medications & Dosage:

Please Answer the Following:

Reason for referral?

How did you become aware of these problems?

What is this person’s ability to provide properly for personal needs?

What is this person’s ability to manage own financial resources?

What alternatives to conservatorship have been considered?

What Health and Social Services have been provided to this individual during the last year?

What estate management or money management services have been provided to this person?

In seeking assistance for this person, what other agencies have you contacted?

Does this person have psychiatric history?